Wong’s Essentials of Pediatric Nursing, 10th Edition – Test Bank

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Wong’s Essentials of Pediatric Nursing, 10th Edition – Test Bank

Chapter 02: Family, Social, Cultural, and Religious Influences on Child Health Promotion

Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. A nurse is selecting a family theory to assess a patient’s family dynamics. Which family theory best describes a series of tasks for the family throughout its life span?
a. Interactional theory
b. Developmental systems theory
c. Structural-functional theory
d. Duvall’s developmental theory

 

 

ANS:  D

Duvall’s developmental theory describes eight developmental tasks of the family throughout its life span. Interactional theory and structural-functional theory are not family theories. Developmental systems theory is an outgrowth of Duvall’s theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others.

 

DIF:    Cognitive Level: Understand          REF:   p. 17

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which family theory explains how families react to stressful events and suggests factors that promote adaptation to these events?
a. Interactional theory
b. Developmental systems theory
c. Family stress theory
d. Duvall’s developmental theory

 

 

ANS:  C

Family stress theory explains the reaction of families to stressful events. In addition, the theory helps suggest factors that promote adaptation to the stress. Stressors, both positive and negative, are cumulative and affect the family. Adaptation requires a change in family structure or interaction. Interactional theory is not a family theory. Interactions are the basis of general systems theory. Developmental systems theory is an outgrowth of Duvall’s theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. Duvall’s developmental theory describes eight developmental tasks of the family throughout its life span.

 

DIF:    Cognitive Level: Understand          REF:   p. 16

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is the term for a family in which the paternal grandmother, the parents, and two minor children live together?
a. Blended
b. Nuclear
c. Binuclear
d. Extended

 

 

ANS:  D

An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. A blended family contains at least one stepparent, step-sibling, or half-sibling. The nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children.

 

DIF:    Cognitive Level: Remember           REF:   p. 18

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is assessing a family’s structure. Which describes a family in which a mother, her children, and a stepfather live together?
a. Blended
b. Nuclear
c. Binuclear
d. Extended

 

 

ANS:  A

A blended family contains at least one stepparent, step-sibling, or half-sibling. The nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling.

 

DIF:    Cognitive Level: Understand          REF:   p. 18

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents of a firstborn child are asking whether it is normal for their child to be extremely competitive. The nurse should respond to the parents that studies about the ordinal position of children suggest that firstborn children tend to:
a. be praised less often.
b. be more achievement oriented.
c. be more popular with the peer group.
d. identify with peer group more than parents.

 

 

ANS:  B

Firstborn children, like only children, tend to be more achievement oriented. Being praised less often, being more popular with the peer group, and identifying with peer groups more than parents are characteristics of later-born children.

 

DIF:    Cognitive Level: Apply                  REF:   p. 29

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching a group of new parents about the experience of role transition. Which statement by a parent would indicate a correct understanding of the teaching?
a. “My marital relationship can have a positive or negative effect on the role transition.”
b. “If an infant has special care needs, the parents’ sense of confidence in their new role is strengthened.”
c. “Young parents can adjust to the new role easier than older parents.”
d. “A parent’s previous experience with children makes the role transition more difficult.”

 

 

ANS:  A

If parents are supportive of each other, they can serve as positive influences on establishing satisfying parental roles. When marital tensions alter caregiving routines and interfere with the enjoyment of the infant, then the marital relationship has a negative effect. Infants with special care needs can be a significant source of added stress. Older parents are usually more able to cope with the greater financial responsibilities, changes in sleeping habits, and reduced time for each other and other children. Parents who have previous experience with parenting appear more relaxed, have less conflict in disciplinary relationships, and are more aware of normal growth and development.

 

DIF:    Cognitive Level: Understand          REF:   p. 17

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. When assessing a family, the nurse determines that the parents exert little or no control over their children. What is this style of parenting called?
a. Permissive
b. Dictatorial
c. Democratic
d. Authoritarian

 

 

ANS:  A

Permissive parents avoid imposing their own standards of conduct and allow their children to regulate their own activity as much as possible. The parents exert little or no control over their children’s actions. Dictatorial or authoritarian parents attempt to control their children’s behavior and attitudes through unquestioned mandates. They establish rules and regulations or standards of conduct that they expect to be followed rigidly and unquestioningly. Democratic parents combine permissive and dictatorial styles. They direct their children’s behavior and attitudes by emphasizing the reasons for rules and negatively reinforcing deviations. They respect the child’s individual nature.

 

DIF:    Cognitive Level: Remember           REF:   p. 20

TOP:   Integrated Process: Nursing Process: Diagnosis

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. When discussing discipline with the mother of a 4-year-old child, the nurse should include which instruction?
a. Children as young as 4 years old rarely need to be punished.
b. Parental control should be consistent.
c. Withdrawal of love and approval is effective at this age.
d. One should expect rules to be followed rigidly and unquestioningly.

 

 

ANS:  B

For effective discipline, parents must be consistent and must follow through with agreed-on actions. Realistic goals should be set for this age group. Parents should structure the environment to prevent unnecessary difficulties. Requests for behavior change should be phrased in a positive manner to provide direction for the child. Withdrawal of love and approval is never appropriate or effective. Discipline strategies should be appropriate to the child’s age, temperament, and severity of the misbehavior. Following rules rigidly and unquestioningly is beyond the developmental capabilities of a 4-year-old.

 

DIF:    Cognitive Level: Apply                  REF:   p. 20

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is most characteristic of the physical punishment of children, such as spanking?
a. Psychological impact is usually minimal.
b. Children rarely become accustomed to spanking.
c. Children’s development of reasoning increases.
d. Misbehavior is likely to occur when parents are not present.

 

 

ANS:  D

Through the use of physical punishment, children learn what they should not do. When parents are not around, it is more likely that children will misbehave because they have not learned to behave well for their own sake, but rather out of fear of punishment. Spanking can cause severe physical and psychological injury and interfere with effective parent-child interaction. Children do become accustomed to spanking, requiring more severe corporal punishment each time. The use of corporal punishment may interfere with the child’s development of moral reasoning.

 

DIF:    Cognitive Level: Understand          REF:   p. 20

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A 3-year-old girl was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guidelines concerning adoption should the nurse use in planning a response?
a. Telling the child is an important aspect of their parental responsibilities.
b. The best time to tell the child is between ages 7 and 10 years.
c. It is not necessary to tell the child who was adopted so young.
d. It is best to wait until the child asks about it.

 

 

ANS:  A

It is important for the parents not to withhold information about the adoption from the child. It is an essential component of the child’s identity. There is no recommended best time to tell children. It is believed that children should be told young enough so they do not remember a time when they did not know. It should be done before the children enter school to keep third parties from telling the children before the parents have had the opportunity.

 

DIF:    Cognitive Level: Understand          REF:   p. 22

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A parent of a school-age child is going through a divorce. The parent tells the school nurse the child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as which implication?
a. Indication of maladjustment
b. Common reaction to divorce
c. Lack of adequate parenting
d. Unusual response that indicates need for referral

 

 

ANS:  B

Parental divorce affects school-age children in many ways. In addition to difficulties in school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of appetite, and sleep disorders. This is not an indication of maladjustment, suggestive of lack of adequate parenting, or an unusual response that indicates need for referral in school-age children after parental divorce.

 

DIF:    Cognitive Level: Apply                  REF:   p. 24

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, “I want to go back to work, but I don’t want Eric to suffer because I’ll have less time with him.” The nurse’s most appropriate answer would be which statement?
a. “I’m sure he’ll be fine if you get a good babysitter.”
b. “You will need to stay home until Eric starts school.”
c. “You should go back to work so Eric will get used to being with others.”
d. “Let’s talk about the child care options that will be best for Eric.”

 

 

ANS:  D

Let’s talk about the child care options that will be best for Eric is an open-ended statement that will assist the mother in exploring her concerns about what is best for both her and Eric. I’m sure he’ll be fine if you get a good babysitter, You will need to stay home until Eric starts school, and You should go back to work so Eric will get used to being with others are directive statements. They do not address the effect of her working on Eric.

 

DIF:    Cognitive Level: Apply                  REF:   p. 27

TOP:   Integrated Process: Communication and Documentation

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Which term best describes a group of people who share a set of values, beliefs, practices, social relationships, law, politics, economics, and norms of behavior?
a. Race
b. Culture
c. Ethnicity
d. Social group

 

 

ANS:  B

Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that serve as a frame of reference for individual perceptions and judgments. Race is defined as a division of humankind possessing traits that are transmissible by descent and are sufficient to characterize it as a distinct human type. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. A social group consists of systems of roles carried out in groups. Examples of primary social groups include the family and peer groups.

 

DIF:    Cognitive Level: Remember           REF:   p. 29

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Which term best describes the emotional attitude that one’s own ethnic group is superior to others?
a. Culture
b. Ethnicity
c. Superiority
d. Ethnocentrism

 

 

ANS:  D

Ethnocentrism is the belief that one’s way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of one’s ethnic group are superior to those of others. Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that serves as a frame of reference for individual perception and judgments. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. Superiority is the state or quality of being superior; it does not include ethnicity.

 

DIF:    Cognitive Level: Understand          REF:   p. 30

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. Dunst, Trivette, and Deal identified the qualities of strong families that help them function effectively. Which qualities are included? (Select all that apply.)
a. Ability to stay connected without spending time together
b. Clear set of family values, rules, and beliefs
c. Adoption of one coping strategy that always promotes positive functioning in dealing with life events
d. Sense of commitment toward growth of individual family members as opposed to that of the family unit
e. Ability to engage in problem-solving activities
f. Sense of balance between the use of internal and external family resources

 

 

ANS:  B, E, F

A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behavior is one of the qualities of strong families that help them function effectively. Strong families also are able to engage in problem-solving activities and to find a balance between internal and external forces. Strong families have a sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs. Strong families also use varied coping strategies. The sense of commitment is toward the growth and well-being of individual family members, as well as the family unit.

 

DIF:    Cognitive Level: Understand          REF:   p. 19

TOP:   Integrated Process: Nursing Process: Diagnosis

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is conducting a teaching session on the use of time-out as a discipline measure to parents of toddlers. Which are correct strategies the nurse should include in the teaching session? (Select all that apply.)
a. Time-out as a discipline measure cannot be used when in a public place.
b. A rule for the length of time-out is 1 minute per year.
c. When the child misbehaves, one warning should be given.
d. The area for time-out can be in the family room where the child can see the television.
e. When the child is quiet for the specified time, he or she can leave the room.

 

 

ANS:  B, C, E

A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an audible bell to record the time rather than a watch. When the child misbehaves, one warning should be given. When the child is quiet for the duration of the time, he or she can then leave the room. Time-out can be used in public places and the parents should be consistent on the use of time-out. Implement time-out in a public place by selecting a suitable area or explain to children that time-out will be spent immediately on returning home. The time-out should not be spent in an area from which the child can view the television. Select an area for time-out that is safe, convenient, and unstimulating but where the child can be monitored, such as the bathroom, hallway, or laundry room.

 

DIF:    Cognitive Level: Apply                  REF:   p. 21

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Divorced parents of a preschool child are asking whether their child will display any feelings or behaviors related to the effect of the divorce. The nurse is correct when explaining that the parents should be prepared for which types of behaviors? (Select all that apply.)
a. Displaying fears of abandonment
b. Verbalizing that he or she “is the reason for the divorce”
c. Displaying fear regarding the future
d. Ability to disengage from the divorce proceedings
e. Engaging in fantasy to understand the divorce

 

 

ANS:  A, B, E

A child 3 to 5 years of age (preschool) may display fears of abandonment, verbalize feelings that he or she is the reason for the divorce, and engage in fantasy to understand the divorce. He or she would not be displaying fear regarding the future until school age, and the ability to disengage from the divorce proceedings would be characteristic of an adolescent.

 

DIF:    Cognitive Level: Apply                  REF:   p. 24

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Teaching and Learning

 

COMPLETION

 

  1. A nurse is admitting a child, in foster care, to the hospital. The nurse recognizes that foster parents care for the child _____ hours a day. (Record your answer as a whole number.)

 

ANS:

24

 

The term foster care is defined as 24-hour substitute care for children outside of their own homes.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

 

Chapter 14: Health Promotion of the School-Age Child and Family

Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is teaching a group of 10- to 12-year-old children about physical development during the school-age years. Which statement made by a participant, indicates the correct understanding of the teaching?
a. “My body weight will be almost triple in the next few years.”
b. “I will grow an average of 2 inches per year from this point on.”
c. “There are not that many physical differences among school-age children.”
d. “I will have a gradual increase in fat, which may contribute to a heavier appearance.”

 

 

ANS:  B

In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 2 inches per year. In middle childhood, children’s weight will almost double; they gain 3 kg/year. At the end of middle childhood, girls grow taller and gain more weight than boys. Children take on a slimmer look with longer legs in middle childhood.

 

DIF:    Cognitive Level: Apply                  REF:   p. 429

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What is the earliest age at which puberty begins?
a. 9
b. 10
c. 11
d. 12

 

 

ANS:  A

There is no universal age at which children assume the characteristics of prepubescence. The first physiologic signs appear at about 9 years of age (particularly in girls) and are usually clearly evident in 11- to 12-year-old children.

 

DIF:    Cognitive Level: Understand          REF:   p. 430

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which describes the cognitive abilities of school-age children?
a. Have developed the ability to reason abstractly
b. Are capable of scientific reasoning and formal logic
c. Progress from making judgments based on what they reason to making judgments based on what they see
d. Are able to classify, to group and sort, and to hold a concept in their minds while making decisions based on that concept

 

 

ANS:  D

In Piaget’s stage of concrete operations, children have the ability to group and sort and make conceptual decisions. Children cannot reason abstractly and logically until late adolescence. Making judgments based on what they reason to making judgments based on what they see is not a developmental skill.

 

DIF:    Cognitive Level: Understand          REF:   p. 431

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which describes moral development in younger school-age children?
a. The standards of behavior now come from within themselves.
b. They do not yet experience a sense of guilt when they misbehave.
c. They know the rules and behaviors expected of them but do not understand the reasons behind them.
d. They no longer interpret accidents and misfortunes as punishment for misdeeds.

 

 

ANS:  C

Children who are ages 6 and 7 years know the rules and behaviors expected of them but do not understand the reasons for these rules and behaviors. Young children do not believe that standards of behavior come from within themselves, but that rules are established and set down by others. Younger school-age children learn standards for acceptable behavior, act according to these standards, and feel guilty when they violate them. Misfortunes and accidents are viewed as punishment for bad acts.

 

DIF:    Cognitive Level: Understand          REF:   p. 431

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which statement characterizes moral development in the older school-age child?
a. They are able to judge an act by the intentions that prompted it rather than just by the consequences.
b. Rules and judgments become more absolute and authoritarian.
c. They view rule violations in an isolated context.
d. They know the rules but cannot understand the reasons behind them.

 

 

ANS:  A

Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rules and judgments become less absolute and authoritarian. Rule violation is likely to be viewed in relation to the total context in which it appears. The situation and the morality of the rule itself influence reactions.

 

DIF:    Cognitive Level: Understand          REF:   p. 431

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. An 8-year-old girl tells the nurse that she has cancer because God is punishing her for “being bad.” She shares her concern that if she dies, she will go to hell. How should the nurse interpret this statement?
a. A common belief at this age
b. A belief that forms the basis for most religions
c. Suggestive of excessive family pressure
d. Suggestive of a failure to develop a conscience

 

 

ANS:  A

Children at this age may view illness or injury as a punishment for a real or imagined misdeed. The belief in divine punishment is common for an 8-year-old child.

 

DIF:    Cognitive Level: Analyze               REF:   p. 432

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents ask the nurse whether it is common for their school-age child to spend a lot of time with peers. The nurse should respond, explaining that the role of the peer group in the life of school-age children provides:
a. opportunity to become defiant.
b. time to remain dependent on their parents for a longer time.
c. time to establish a one-on-one relationship with the opposite sex.
d. security as they gain independence from their parents.

 

 

ANS:  D

Peer-group identification is an important factor in gaining independence from parents. Children learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. Becoming defiant in a peer-group relationship may lead to bullying. Peer-group identification helps in gaining independence rather than remaining dependent. One-on-one opposite sex relationships do not occur until adolescence. School-age children form peer groups of the same sex.

 

DIF:    Cognitive Level: Understand          REF:   p. 433

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A group of boys ages 9 and 10 years have formed a “boys-only” club that is open to neighborhood and school friends who have skateboards. How should this be interpreted?
a. Behavior that encourages bullying and sexism
b. Behavior that reinforces poor peer relationships
c. Characteristic of social development at this age
d. Characteristic of children who later are at risk for membership in gangs

 

 

ANS:  C

One of the outstanding characteristics of middle childhood is the creation of formalized groups or clubs. Peer-group identification and association are essential to a child’s socialization. Poor relationships with peers and a lack of group identification can contribute to bullying. A boys-only club does not have a direct correlation with later gang activity.

 

DIF:    Cognitive Level: Analyze               REF:   p. 433

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A school nurse observes school-age children playing at recess. Which is descriptive of the play the nurse expects to observe?
a. Individuality in play is better tolerated than at earlier ages.
b. Knowing the rules of a game gives an important sense of belonging.
c. They like to invent games, making up the rules as they go.
d. Team play helps children learn the universal importance of competition and winning.

 

 

ANS:  B

Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States.

 

DIF:    Cognitive Level: Understand          REF:   p. 437

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Bullying can be common during the school-age years. The nurse should recognize that which applies to bullying?
a. Can have a lasting effect on children
b. Is not a significant threat to self-concept
c. Is rarely based on anything that is concrete
d. Is usually ignored by the child who is being bullied

 

 

ANS:  A

Bullying in this age group is common and can have a long-lasting effect. Increasing awareness of differences, especially when accompanied by unkind comments and taunts from others, may make a child feel inferior and undesirable. Physical impairments such as hearing or visual defects, ears that “stick out,” or birth marks assume great importance.

 

DIF:    Cognitive Level: Understand          REF:   p. 439

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is characteristic of dishonest behavior in children ages 8 to 10 years?
a. Cheating during games is now more common.
b. Lying results from the inability to distinguish between fact and fantasy.
c. They may steal because their sense of property rights is limited.
d. They may lie to meet expectations set by others that they have been unable to attain.

 

 

ANS:  D

Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. In this age group, children are able to distinguish between fact and fantasy. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems.

 

DIF:    Cognitive Level: Understand          REF:   p. 439

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says she is completing her schoolwork satisfactorily but lately has been somewhat aggressive and stubborn in the classroom. How should the nurse interpret this behavior?
a. A sign of stress
b. A developmental delay
c. A physical problem
d. A lack of adjustment to school

 

 

ANS:  A

Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to early behaviors. This child is exhibiting signs of stress.

 

DIF:    Cognitive Level: Apply                  REF:   p. 439

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which statement best describes fear in the school-age child?
a. They are increasingly fearful for body safety.
b. Most of the new fears that trouble them are related to school and family.
c. They should be encouraged to hide their fears to prevent ridicule by peers.
d. Those who have numerous fears need continuous protective behavior by parents to eliminate these fears.

 

 

ANS:  B

During the school-age years, children experience a wide variety of fears, but new fears relate predominantly to school and family. During the middle-school years, children become less fearful for body safety than they were as preschoolers. Parents and other persons involved with children should discuss children’s fears with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding their fears does not end them and may lead to phobias.

 

DIF:    Cognitive Level: Analyze               REF:   p. 439

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The father of a 12-year-old child tells the nurse that he is concerned about his son getting “fat.” His son is at the 50th percentile for height and the 75th percentile for weight on the growth chart. What is the most appropriate nursing action?
a. Reassure the father that his child is not fat
b. Reassure the father that his child is just growing
c. Suggest a low-calorie, low-fat diet
d. Explain that this is typical of the growth pattern of boys at this age

 

 

ANS:  D

This is a characteristic pattern of growth in preadolescent boys, where the growth in height has slowed in preparation for the pubertal growth spurt, but weight is still gained. The nurse should review this with both the father and the child and develop a plan to maintain physical exercise and a balanced diet. It is false reassurance to tell the father that his son is not fat. His weight is high for his height. The child needs to maintain his physical activity. The father is concerned, so an explanation is required. A nutritional diet with physical activity should be sufficient to maintain his balance.

 

DIF:    Cognitive Level: Apply                  REF:   p. 440

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A child has an evulsed (knocked-out) tooth. Which medium should the nurse instruct the parents to place the tooth in for transport to the dentist?
a. In cold milk
b. In cold water
c. In warm salt water
d. In a dry, clean jar

 

 

ANS:  A

An evulsed tooth should be placed in a suitable medium for transplant, either cold milk or saliva (under the child or parent’s tongue). Cold milk is a more suitable medium for transport than cold water, warm salt water, or a dry, clean jar.

 

DIF:    Cognitive Level: Apply                  REF:   p. 441

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The school nurse has been asked to begin teaching sex education in the fifth grade. What should the nurse recognize about this age group?
a. Children in fifth grade are too young for sex education.
b. Children should be discouraged from asking too many questions.
c. Correct terminology should be reserved for children who are older.
d. Sex can be presented as a normal part of growth and development.

 

 

ANS:  D

When sexual information is presented to school-age children, sex should be treated as a normal part of growth and development. Fifth-graders are usually 10 or 11 years old. This age is not too young to speak about physiologic changes in their bodies. They should be encouraged to ask questions. Preadolescents need precise and concrete information.

 

DIF:    Cognitive Level: Apply                  REF:   p. 445

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The school nurse is conducting a class on bicycle safety. Which statement made by a participant indicates a need for further teaching?
a. “Most bicycle injuries occur from a fall off the bicycle.”
b. “Head injuries are the major causes of bicycle-related fatalities.”
c. “I should replace my helmet every 5 years.”
d. “I can ride double with a friend if the bicycle has an extra-large seat.”

 

 

ANS:  D

Children should not ride double. Most injuries result from falls. The most important aspect of bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major cause of bicycle-related fatalities. The child should always wear a properly fitted helmet approved by the US Consumer Product Safety Commission and should replace the helmet at least every 5 years.

 

DIF:    Cognitive Level: Apply                  REF:   p. 445

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control

 

  1. When teaching injury prevention during the school-age years, what should the nurse include?
a. Teach children to fear strangers.
b. Teach basic rules of water safety.
c. Avoid letting child cook in microwave ovens.
d. Caution child against engaging in competitive sports.

 

 

ANS:  B

Water safety instruction is an important source of injury prevention at this age. The child should be taught to swim, select safe and supervised places to swim, swim with a companion, check for sufficient water depth before diving, and use an approved flotation device. Teach stranger safety, not fear of strangers. This includes instructing children to not go with strangers, not wear personalized clothing in public places, tell parents if anyone makes child feel uncomfortable, and say “no” in uncomfortable situations. Teach child safe cooking. Caution against engaging in hazardous sports such as those involving trampolines.

 

DIF:    Cognitive Level: Apply                  REF:   p. 444

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control

 

  1. A nurse is teaching parents of kindergarten children general guidelines to assist their children in school. Which statement by the parents indicates they understand the teaching?
a. “We will only meet with the teacher if problems occur.”
b. “We will discourage hobbies so our child focuses on schoolwork.”
c. “We will plan a trip to the library as often as possible.”
d. “We will expect our child to make all As in school.”

 

 

ANS:  C

General guidelines for parents to help their child in school include sharing an interest in reading. The library should be used frequently, and books the child is reading should be discussed. Hobbies should be encouraged. The parents should not expect all As. They should focus on growth more than grades.

 

DIF:    Cognitive Level: Apply                  REF:   p. 438

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A school nurse is teaching dental health practices to a group of sixth-grade children. How often should the nurse recommend the children brush their teeth?
a. Twice a day
b. Three times a day
c. After meals
d. After meals, after snacks, and at bedtime

 

 

ANS:  D

Teeth should be brushed after meals, after snacks, and at bedtime. Children who brush their teeth frequently and become accustomed to the feel of a clean mouth at an early age usually maintain the habit throughout life. Twice a day, three times a day, or after meals would not be often enough.

 

DIF:    Cognitive Level: Comprehend        REF:   p. 441

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents of a 12-year-old child ask the clinic nurse, “How many hours of sleep should our child get?” The nurse should respond that 12-year-old children need how many hours of sleep at night?
a. 8
b. 9
c. 10
d. 11

 

 

ANS:  B

School-age children usually do not require naps, but they do need to sleep approximately 11 hours at age 5 years and 9 hours at age 12 years each night.

 

DIF:    Cognitive Level: Apply                  REF:   p. 440

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse planning care for a school-age child should take into account that which thought process is seen at this age?
a. Animism
b. Magical thinking
c. Ability to conserve
d. Thoughts are all-powerful

 

 

ANS:  C

One cognitive task of school-age children is mastering the concept of conservation. At an early age (5 to 7 years), children grasp the concept of reversibility of numbers as a basis for simple mathematics problems (e.g., 2 + 4 = 6 and 6 – 4 = 2). They learn that simply altering their arrangement in space does not change certain properties of the environment, and they are able to resist perceptual cues that suggest alterations in the physical state of an object. Animism, magical thinking, and believing that thoughts are all powerful are thought processes seen in preschool children.

 

DIF:    Cognitive Level: Apply                  REF:   p. 432

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A school-age child falls on the playground and has a small laceration on the forearm. The school nurse should do which to cleanse the wound?
a. Slowly pour hydrogen peroxide over wound.
b. Soak arm in warm water and soap for at least 30 minutes.
c. Gently cleanse with sterile pad and a non-stinging povidone-iodine solution.
d. Wash wound gently with mild soap and water for several minutes.

 

 

ANS:  D

Lacerations should be washed gently with mild soap and water or normal saline. A sterile pad is not necessary, and hydrogen peroxide and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection. Soaking the arm will not effectively clean the wound.

 

DIF:    Cognitive Level: Apply                  REF:   p. 434

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. A nurse is planning care for a 7-year-old child hospitalized with osteomyelitis. Which activities should the nurse plan to bring from the playroom for the child? (Select all that apply.)
a. Paper and some paints
b. Board games
c. Jack-in-the-box
d. Stuffed animals
e. Computer games

 

 

ANS:  A, B, E

School-age children become fascinated with complex board, card, or computer games that they can play alone, with a best friend, or with a group. They also enjoy sewing, cooking, carpentry, gardening, and creative activities such as painting. Jack-in-the-box and stuffed animals would be appropriate for a toddler or preschool child.

 

DIF:    Cognitive Level: Apply                  REF:   p. 435

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse teaches parents that team play is important for school-age children. Which can children develop by experiencing team play? (Select all that apply.)
a. Achieve personal goals over group goals.
b. Learn complex rules.
c. Experience competition.
d. Learn about division of labor.

 

 

ANS:  B, C, D

Team play helps stimulate cognitive growth because children are called on to learn many complex rules, make judgments about those rules, plan strategies, and assess the strengths and weaknesses of members of their own team and members of the opposing team. Team play can also contribute to children’s social, intellectual, and skill growth. Children work hard to develop the skills needed to become team members, to improve their contribution to the group, and to anticipate the consequences of their behavior for the group. Team play teaches children to modify or exchange personal goals for goals of the group; it also teaches them that division of labor is an effective strategy for attaining a goal.

 

DIF:    Cognitive Level: Apply                  REF:   p. 435

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

Chapter 30: The Child with Neuromuscular or Muscular Dysfunction

Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is planning a staff in-service on childhood spastic cerebral palsy. What characterizes spastic cerebral palsy?
a. Hypertonicity and poor control of posture, balance, and coordinated motion
b. Athetosis and dystonic movements
c. Wide-based gait and poor performance of rapid, repetitive movements
d. Tremors and lack of active movement

 

 

ANS:  A

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.

 

DIF:    Cognitive Level: Understand          REF:   p. 978

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their child’s spasticity. The nurse’s response should be based on which statement?
a. Anticonvulsant medications are sometimes useful for controlling spasticity.
b. Medications that would be useful in reducing spasticity are too toxic for use with children.
c. Many different medications can be highly effective in controlling spasticity.
d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.

 

 

ANS:  D

Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are currently available for the control of spasticity.

 

DIF:    Cognitive Level: Understand          REF:   p. 979

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborn’s defect?
a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed
b. Herniation of the brain and meninges through a defect in the skull
c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements
d. Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves

 

 

ANS:  D

A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.

 

DIF:    Cognitive Level: Understand          REF:   p. 984

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect?
a. Hydrocephalus
b. Craniostenosis
c. Biliary atresia
d. Esophageal atresia

 

 

ANS:  A

Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniostenosis is the preterm closing of the cranial sutures and is not associated with myelomeningocele. Biliary and esophageal atresia is not associated with myelomeningocele.

 

DIF:    Cognitive Level: Understand          REF:   p. 984

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is teaching a group of nursing students about newborns born with the congenital defect of myelomeningocele. Which common problem is associated with this defect?
a. Neurogenic bladder
b. Cognitive impairment
c. Respiratory compromise
d. Cranioschisis

 

 

ANS:  A

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. Risk of cognitive impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

 

DIF:    Cognitive Level: Understand          REF:   p. 987

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is reviewing prenatal vitamin supplements with an expectant client. Which supplement should be included in the teaching?
a. Vitamin A throughout pregnancy
b. Multivitamin preparations as soon as pregnancy is suspected
c. Folic acid for all women of childbearing age
d. Folic acid during the first and second trimesters of pregnancy

 

 

ANS:  C

The widespread use of folic acid among women of childbearing age has decreased the incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina bifida. Folic acid supplementation is recommended for the preconception period and during the pregnancy. Only 42% of women actually follow these guidelines.

 

DIF:    Cognitive Level: Understand          REF:   p. 988

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. How much folic acid is recommended for women of childbearing age?
a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg

 

 

ANS:  B

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age will prevent 50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0 mg are not the recommended dosages of folic acid.

 

DIF:    Cognitive Level: Remember           REF:   p. 988

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. Which describes the most appropriate way to position and feed this neonate?
a. Prone and tube-fed
b. Prone, head turned to side, and nipple-fed
c. Supine in an infant carrier and nipple-fed
d. Supine, with defect supported with rolled blankets, and nipple-fed

 

 

ANS:  B

In the prone position, feeding is a problem. The infant’s head is turned to one side for feeding. If the child is able to nipple-feed, tube feeding is not needed. Before surgery, the infant is kept in the prone position to minimize tension on the sac and risk of trauma.

 

DIF:    Cognitive Level: Apply                  REF:   p. 988

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. The nurse is talking to a parent with a child who has a latex allergy. Which statement by the parent would indicate a correct understanding of the teaching?
a. “My child will have an allergic reaction if he comes in contact with yeast products.”
b. “My child may have an upset stomach if he eats a food made with wheat or barley.”
c. “My child will probably develop an allergy to peanuts.”
d. “My child should not eat bananas or kiwis.”

 

 

ANS:  D

There are cross-reactions between latex allergies and a number of foods such as bananas, avocados, kiwi, and chestnuts. Children with a latex allergy will not develop allergies to other food products such as yeast, wheat, barley, or peanuts.

 

DIF:    Cognitive Level: Analyze               REF:   p. 990

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action?
a. Avoid using any latex product.
b. Use only nonallergenic latex products.
c. Administer medication for long-term desensitization.
d. Teach family about long-term management of asthma.

 

 

ANS:  A

Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. There are no nonallergenic latex products. At this time, desensitization is not an option. The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

 

DIF:    Cognitive Level: Apply                  REF:   p. 990

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type 1). Which signs and symptoms are associated with this disease?
a. Spinal muscular atrophy
b. Neural atrophy of muscles
c. Progressive weakness and wasting of skeletal muscle
d. Pseudohypertrophy of certain muscle groups

 

 

ANS:  C

Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells. Kugelberg-Welander disease is a juvenile spinal muscular atrophy with a later onset. Charcot-Marie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the peroneal nerves. Progressive weakness is found of the distal muscles of the arms and feet. Duchenne muscular dystrophy is characterized by muscles, especially in the calves, thighs, and upper arms, which become enlarged from fatty infiltration and feel unusually firm or woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.

 

DIF:    Cognitive Level: Understand          REF:   p. 991

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy (Werdnig-Hoffmann disease)?
a. Hyperactive deep tendon reflexes
b. Hypertonicity
c. Lying in the frog position
d. Motor deficits on one side of body

 

 

ANS:  C

The infant lies in the frog position with the legs externally rotated, abducted, and flexed at the knees. The deep tendon reflexes are absent. The child has hypotonia and inactivity as the most prominent features. The motor deficits are bilateral.

 

DIF:    Cognitive Level: Understand          REF:   p. 991

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action?
a. Recommend genetic counseling.
b. Explain that the disease is easily treated.
c. Suggest ways to limit use of muscles.
d. Assist family in finding a nursing facility to provide child’s care.

 

 

ANS:  A

Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to provide the child’s care is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.

 

DIF:    Cognitive Level: Understand          REF:   p. 992

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. What should be administered to a child with tetanus?
a. Nonsteroidal antiinflammatory drugs (NSAIDs) to reduce inflammation.
b. Muscle stimulants to counteract muscle weakness.
c. Bronchodilators to prevent respiratory complications.
d. Tetanus immunoglobulin therapy.

 

 

ANS:  D

Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus. Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression. Bronchodilators would not be used unless specifically indicated.

 

DIF:    Cognitive Level: Understand          REF:   p. 997

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy?
a. Tonic neck reflex at 5 months of age
b. Absent Moro reflex at 8 months of age
c. Moro reflex at 3 months of age
d. Extensor reflex at 7 months of age

 

 

ANS:  D

Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with the knee extended. Normally, the contralateral foot responds with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these reflexes occur after 4 months.

 

DIF:    Cognitive Level: Apply                  REF:   p. 979

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the morning. Which intervention should the nurse plan for the care of the myelomeningocele sac?
a. Open to air
b. Covered with a sterile, moist, nonadherent dressing
c. Reinforcement of the original dressing if drainage noted
d. A diaper secured over the dressing

 

 

ANS:  B

Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not placed over the dressing because stool contamination can occur.

 

DIF:    Cognitive Level: Apply                  REF:   p. 987

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is admitting a school-age child with suspected Guillain-Barré syndrome (GBS). Which is a priority in the care for this child?
a. Monitoring intake and output
b. Assessing respiratory efforts
c. Placing on a telemetry monitor
d. Obtaining laboratory studies

 

 

ANS:  B

Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory compromise, intravenous (IV) administration of immunoglobulin (IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be used. Intake and output, telemetry monitoring, and obtaining laboratory studies may be part of the plan of care but are not the priority.

 

DIF:    Cognitive Level: Analyze               REF:   p. 996

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit. Which health care provider prescription should the nurse clarify with the health care provider before implementing?
a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time.
b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously.
c. Titrate oxygen to keep pulse oximetry saturations greater than 92.
d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every 12 hours.

 

 

ANS:  D

The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic therapy is not part of the management of infant botulism because the botulinum toxin is an intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular should not be administered because they may potentiate the blocking effects of the neurotoxin. Treatment consists of immediate administration of botulism immune globulin intravenously (BIG-IV) without delaying for laboratory diagnosis. Early administration of BIG-IV neutralizes the toxin and stops the progression of the disease. The human-derived botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in infant botulism. Approximately 50% of affected infants require intubation and mechanical ventilation; therefore, respiratory support is crucial, as is nutritional support, because these infants are unable to feed.

 

DIF:    Cognitive Level: Analyze               REF:   p. 999

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first?
a. Place the adolescent in a flat right side-lying position.
b. Place a cool washcloth on the adolescent’s forehead and continue to monitor the blood pressure.
c. Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter.
d. Take a full set of vital signs and notify the health care provider.

 

 

ANS:  C

The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is relieved. Placing a cool washcloth on the adolescent’s forehead, continuing to monitor blood pressure and vital signs, and notifying the health care provider would not reverse the sympathetic reflex situation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 1000

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A child steps on a nail and sustains a puncture wound of the foot. Which is the most appropriate method for cleansing this wound?
a. Wash wound thoroughly with chlorhexidine.
b. Wash wound thoroughly with povidone-iodine.
c. Soak foot in warm water and soap.
d. Soak foot in solution of 50% hydrogen peroxide and 50% water.

 

 

ANS:  C

Puncture wounds should be cleansed by soaking the foot in warm water and soap. Chlorhexidine, hydrogen peroxide, and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection.

 

DIF:    Cognitive Level: Apply                  REF:   p. 998

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes which action(s)? (Select all that apply.)
a. Monitoring and maintaining systemic blood pressure
b. Administering corticosteroids
c. Minimizing environmental stimuli
d. Discussing long-term care issues with the family
e. Monitoring for respiratory complications

 

 

ANS:  A, B, E

Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. It is not necessary to minimize environmental stimuli for this type of injury. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

 

DIF:    Cognitive Level: Apply                  REF:   p. 1000

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.)
a. Lordosis
b. Gower sign
c. Kyphosis
d. Scoliosis
e. Waddling gait

 

 

ANS:  A, B, E

Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment findings with DMD.

 

DIF:    Cognitive Level: Apply                  REF:   p. 992

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is conducting discharge teaching to parents of a preschool child with myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract infection (UTI). Which should the nurse include in the discharge instructions related to management of the child’s genitourinary function? (Select all that apply.)
a. Continue to perform the clean intermittent catheterizations (CIC) at home.
b. Administer the oxybutynin chloride (Ditropan) as prescribed.
c. Reduce fluid intake in the afternoon and evening hours.
d. Monitor for signs of a recurrent urinary tract infection.
e. Administer furosemide (Lasix) as prescribed.

 

 

ANS:  A, B, D

Discharge teaching to prevent renal complications in a child with myelomeningocele include: (1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of regular emptying of the bladder, such as CIC taught to and performed by parents and self-catheterization taught to children; (3) medications to improve bladder storage and continence, such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited and Lasix is not used to improve renal function for children with myelomeningocele.

 

DIF:    Cognitive Level: Apply                  REF:   p. 984

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with Guillain-Barré syndrome (GBS)? (Select all that apply.)
a. Decreased protein concentration
b. Normal glucose
c. Fewer than 10 white blood cells (WBCs/mm3)
d. Elevated red blood cell (RBC) count

 

 

ANS:  B, C

Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF analysis reveals an abnormally elevated protein concentration, normal glucose, and fewer than 10 WBCs/mm3. CSF fluid should not contain RBCs.

 

DIF:    Cognitive Level: Understand          REF:   p. 996

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant? (Select all that apply.)
a. Temperature instability
b. Irritability
c. Lethargy
d. Bradycardia
e. Hypertension

 

 

ANS:  A, B, C

The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.

 

DIF:    Cognitive Level: Analyze               REF:   p. 989

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

SHORT ANSWER

 

  1. A toddler is admitted to the hospital with a possible diagnosis of tetanus. The health care provider has prescribed lorazepam (Ativan) intravenously 0.05 mg/kg/dose every 6 hours prn as a muscle relaxant. The child weighs 22 pounds. How many milligrams of Ativan should the nurse administer per dose? (Record your answer using one decimal place.)

 

ANS:

0.5

 

Find the child’s weight in kilograms by dividing 22 by 2.2 = 22/2.2 = 10 kg. Multiply the 0.05 mg dose by 10 = 0.05 mg ´ 10 kg = 0.5 mg per dose.

 

DIF:    Cognitive Level: Analyze               REF:   p. 998

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

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