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 10: Health Problems of Infants

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

 

MULTIPLE CHOICE

 

  1. Recent studies indicate that a deficiency of which vitamin correlates with increased morbidity and mortality in children with measles?
a. A
b. C
c. Niacin
d. Folic acid

 

 

ANS:  A

Vitamin A deficiency is correlated with increased morbidity and mortality in children with measles. This vitamin deficiency also is associated with complications from diarrhea, and infections are often increased in infants and children with vitamin A deficiency. No correlation exists between vitamin C, niacin, or folic acid and measles.

 

DIF:    Cognitive Level: Remember           REF:   p. 331

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which vitamin is recommended for all women of childbearing age to reduce the risk of neural tube defects such as spina bifida?
a. A
b. C
c. Niacin
d. Folic acid

 

 

ANS:  D

The vitamin supplement that is recommended for all women of childbearing age is a daily dose of 0.4 mg of folic acid. Folic acid taken before conception and during pregnancy can reduce the risk of neural tube defects by 70%. No correlation exists between vitamins A, C, or folic acid and neural tube defects.

 

DIF:    Cognitive Level: Remember           REF:   p. 331

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the nurse expect?
a. Thin wasted extremities with a prominent abdomen
b. Constipation
c. Elevated hemoglobin
d. High levels of protein

 

 

ANS:  A

The child with kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). Diarrhea (persistent diarrhea malnutrition syndrome) not constipation commonly occurs from a lowered resistance to infection and further complicates the electrolyte imbalance. Anemia and protein deficiency are common findings in malnourished children with kwashiorkor.

 

DIF:    Cognitive Level: Understand          REF:   p. 332

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is preparing to accompany a medical mission’s team to a third world country. Marasmus is seen frequently in children 6 months to 2 years in this country. Which symptoms should the nurse expect for this condition?
a. Loose, wrinkled skin
b. Edematous skin
c. Depigmentation of the skin
d. Dermatoses

 

 

ANS:  A

Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears to be very old, with loose and wrinkled skin, unlike the child with kwashiorkor, who appears more rounded from the edema. Fat metabolism is less impaired than in kwashiorkor; thus, deficiency of fat-soluble vitamins is usually minimal or absent. In general, the clinical manifestations of marasmus are similar to those seen in kwashiorkor with the following exceptions: With marasmus, there is no edema from hypoalbuminemia or sodium retention, which contributes to a severely emaciated appearance; no dermatoses caused by vitamin deficiencies; little or no depigmentation of hair or skin; moderately normal fat metabolism and lipid absorption; and a smaller head size and slower recovery after treatment.

 

DIF:    Cognitive Level: Understand          REF:   p. 332

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Rickets is caused by a deficiency in:
a. vitamin A.
b. vitamin C.
c. vitamin D and calcium.
d. folic acid and iron.

 

 

ANS:  C

Fat-soluble vitamin D and calcium are necessary in adequate amounts to prevent the development of rickets. No correlation exists between vitamins A, C, folic acid, or iron and rickets.

 

DIF:    Cognitive Level: Remember           REF:   p. 330

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is preparing to administer an oral iron supplement to a hospitalized infant. Which should not be given simultaneously with the iron supplement?
a. Milk
b. Multivitamin
c. Fruit juice
d. Meat, fish, poultry

 

 

ANS:  A

Many foods interfere with iron absorption and should be avoided when the iron is consumed. These foods include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables. Multivitamins may contain iron; no contraindication exists to taking the two together. Vitamin C–containing juices enhance the absorption of iron. Meat, fish, and poultry do not have an effect on absorption.

 

DIF:    Cognitive Level: Understand          REF:   p. 331

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse counsels the parents that which vitamin can cause a toxic reaction at a low dose?
a. Niacin
b. B6
c. D
d. C

 

 

ANS:  C

Hypervitaminosis of vitamin D presents the greatest problem because this fat-soluble vitamin is stored in the body. Vitamin D is the most likely of all vitamins to cause toxic reactions in relatively small overdoses. The water-soluble vitamins, primarily niacin, B6, and C, can also cause toxicity but not at the low dose that occurs with vitamin D.

 

DIF:    Cognitive Level: Understand          REF:   p. 331

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child. Which is most likely lacking in their particular diet?
a. Fat
b. Protein
c. Vitamins C and A
d. Complete protein

 

 

ANS:  D

The vegetarian diet can be extremely healthy, meeting the overall nutrition objectives for Healthy People. Parents should be taught about food preparation to ensure that complete proteins are available for growth. When parents use a strict vegetarian diet, likelihood exists of inadequate protein for growth and calories for energy. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available. Foods must be combined to provide complete proteins for growth.

 

DIF:    Cognitive Level: Understand          REF:   p. 331

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which describes marasmus?
a. Deficiency of protein with an adequate supply of calories
b. Not confined to geographic areas where food supplies are inadequate
c. Syndrome that results solely from vitamin deficiencies
d. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)

 

 

ANS:  B

Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic areas were food supplies are inadequate. Marasmus is a deficiency of both protein and calories. It is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears very old, with flabby and wrinkled skin.

 

DIF:    Cognitive Level: Remember           REF:   p. 332

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Although infants may be allergic to a variety of foods, the most common allergens are:
a. fruit and eggs.
b. fruit, vegetables, and wheat.
c. cow’s milk and green vegetables.
d. eggs, cow’s milk, and wheat.

 

 

ANS:  D

Milk products, eggs, and wheat are three of the most common food allergens. Ingestion of these products can cause sensitization and, with subsequent exposure, an allergic reaction. Eggs are a common allergen, but fruit is not. Wheat is a common allergen, but fruit and vegetables are not. Cow’s milk is a common allergen, but green vegetables are not.

 

DIF:    Cognitive Level: Remember           REF:   p. 333

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Cow’s milk allergy (CMA) is diagnosed in a 6-month-old infant. Which should the nurse recommend as a substitute formula?
a. Nutramigen
b. Goat’s milk
c. Similac
d. Enfamil

 

 

ANS:  A

Treatment of CMA is elimination of cow’s milk–based formula and all other dairy products. For infants fed cow’s milk formula, this primarily involves changing the formula to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum). Goat’s milk (raw) is not an acceptable substitute because it cross-reacts with cow’s milk protein, is deficient in folic acid, has a high sodium and protein content, and is unsuitable as the only source of calories. Cow’s milk protein is contained in both Enfamil and Similac.

 

DIF:    Cognitive Level: Apply                  REF:   p. 336

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the teaching plan?
a. Avoid use of pacifiers.
b. Eliminate all second-hand smoke contact.
c. Lay infant flat after feeding.
d. Avoid swaddling the infant.

 

 

ANS:  B

To prevent and treat colic, teach parents that if household members smoke, avoid smoking near infant; preferably confine smoking activity to outside of home. A pacifier can be introduced for added sucking. The infant should be swaddled tightly with a soft, stretchy blanket and placed in an upright seat after feedings.

 

DIF:    Cognitive Level: Apply                  REF:   p. 336

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A parent of an infant with colic tells the nurse, “All this baby does is scream at me; it is a constant worry.” What is the nurse’s best action?
a. Encourage parent to verbalize feelings.
b. Encourage parent not to worry so much.
c. Assess parent for other signs of inadequate parenting.
d. Reassure parent that colic rarely lasts past age 9 months.

 

 

ANS:  A

Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parent’s anxieties. The nurse should reassure the parent that he or she is not doing anything wrong. Colic is multifactorial. The infant with colic is experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will eventually go away does not help him or her through the current situation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 342

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Parent guidelines for relieving colic in an infant include:
a. avoiding touching abdomen.
b. avoiding using a pacifier.
c. changing infant’s position frequently.
d. placing infant where family cannot hear the crying.

 

 

ANS:  C

Changing the infant’s position frequently may be beneficial. The parent can walk holding the child face down and with the child’s chest across the parent’s arm. The parent’s hand can support the child’s abdomen, applying gentle pressure. Gently massaging the abdomen is effective in some children. Pacifiers can be used for meeting additional sucking needs. The child should not be placed where monitoring cannot be done. The child can be placed in the crib and allowed to cry. Periodically, the child should be picked up and comforted.

 

DIF:    Cognitive Level: Apply                  REF:   p. 342

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories include:
a. avoidance of eye contact.
b. an associated malabsorption defect.
c. weight that falls below the 15th percentile.
d. normal achievement of developmental landmarks.

 

 

ANS:  A

One of the clinical manifestations of nonorganic failure to thrive is the child’s avoidance of eye contact with the health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is indicative of failure to thrive. Developmental delays, including social, motor, adaptive, and language, exist.

 

DIF:    Cognitive Level: Understand          REF:   p. 337

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is an important nursing consideration when caring for an infant with failure to thrive?
a. Establish a structured routine and follow it consistently.
b. Maintain a nondistracting environment by not speaking to child during feeding.
c. Place child in an infant seat during feedings to prevent overstimulation.
d. Limit sensory stimulation and play activities to alleviate fatigue.

 

 

ANS:  A

The infant with failure to thrive should have a structured routine that is followed consistently. Disruptions in other activities of daily living can have a great impact on feeding behaviors. Bathing, sleeping, dressing, playing, and feeding are structured. The nurse should talk to the child by giving directions about eating. This will help the child maintain focus. Young children should be held while being fed, and older children can sit at a feeding table. The child should be fed in the same manner at each meal. The child can engage in sensory and play activities at times other than mealtime.

 

DIF:    Cognitive Level: Apply                  REF:   p. 337

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)?
a. Explain how SIDS could have been predicted and prevented.
b. Interview parents in depth concerning the circumstances surrounding the child’s death.
c. Discourage parents from making a last visit with the infant.
d. Make a follow-up home visit to parents as soon as possible after the child’s death.

 

 

ANS:  D

A competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS. An explanation of how SIDS could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. Parents should be allowed and encouraged to make a last visit with their child.

 

DIF:    Cognitive Level: Apply                  REF:   p. 343

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Which is an appropriate action when an infant becomes apneic?
a. Shake vigorously
b. Roll head side to side
c. Hold by feet upside down with head supported
d. Gently stimulate trunk by patting or rubbing

 

 

ANS:  D

If the infant is apneic, the infant’s trunk should be gently stimulated by patting or rubbing. If the infant is prone, turn onto the back. The infant should not be shaken vigorously, the head rolled side to side, or held by the feet upside down with the head supported. These can cause injury.

 

DIF:    Cognitive Level: Apply                  REF:   p. 349

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. To prevent plagiocephaly, the nurse should teach parents to:
a. place infant prone for 30 to 60 minutes per day.
b. buy a soft mattress.
c. allow infant to nap in the car safety seat.
d. have infant sleep with the parents.

 

 

ANS:  A

Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or “tummy time” for approximately 30 to 60 minutes per day when the infant is awake. Soft mattresses or sleeping with parents (co-sleeping) are not recommended because they put the infant at a higher risk for a sudden infant death incident. To prevent plagiocephaly, prolonged placement in car safety seats should be avoided.

 

DIF:    Cognitive Level: Apply                  REF:   p. 348

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency department. Which is an appropriate question to ask the parents?
a. “Did you hear the infant cry out?”
b. “Why didn’t you check on the infant earlier?”
c. “What time did you find the infant?”
d. “Was the head buried in a blanket?”

 

 

ANS:  C

During a SIDS incident, if the infant is not pronounced dead at the scene, he or she may be transported to the emergency department to be pronounced dead by a physician. While they are in the emergency department, the parents are asked only factual questions, such as when they found the infant, how he or she looked, and whom they called for help. The nurse avoids any remarks that may suggest responsibility, such as “Why didn’t you go in earlier?” “Didn’t you hear the infant cry out?” “Was the head buried in a blanket?”

 

DIF:    Cognitive Level: Apply                  REF:   p. 347

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. An infant experienced an apparent life-threatening event (ALTE) and is being placed on home apnea monitoring. Parents have understood the instructions for use of a home apnea monitor when they state?
a. “We can adjust the monitor to eliminate false alarms.”
b. “We should sleep in the same bed as our monitored infant.”
c. “We will check the monitor several times a day to be sure the alarm is working.”
d. “We will place the monitor in the crib with our infant.”

 

 

ANS:  C

The parents should check the monitor several times a day to be sure the alarm is working and that it can be heard from room to room. The parents should not adjust the monitor to eliminate false alarms. Adjustments could compromise the monitor’s effectiveness. The monitor should be placed on a firm surface away from the crib and drapes. The parents should not sleep in the same bed as the monitored infant.

 

DIF:    Cognitive Level: Apply                  REF:   p. 349

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. What should the nurse suggest to the parents of an infant who has a prolonged need for middle-of-the-night feedings?
a. Decrease daytime feedings.
b. Allow child to go to sleep with a bottle.
c. Offer last feeding as late as possible at night.
d. Put infant to bed after asleep from rocking.

 

 

ANS:  C

To manage an infant who has a prolonged need for middle-of-the-night feedings parents should be taught to offer last feeding as late as possible at night. Parent should increase daytime feeding intervals to 4 hours or more (may need to be done gradually), offer no bottles in bed, put to bed awake and when child is crying, check at progressively longer intervals each night; reassure child but do not hold, rock, take to parent’s bed, or give bottle or pacifier.

 

DIF:    Cognitive Level: Apply                  REF:   p. 349

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention should the nurse implement?
a. Provide stimulation during feeding.
b. Avoid being persistent during feeding time.
c. Limit feeding time to 10 minutes.
d. Maintain a face-to-face posture with the infant during feeding.

 

 

ANS:  D

The nurse preparing to feed an infant with failure to thrive should maintain a face-to-face posture with the infant when possible. Encourage eye contact and remain with the infant throughout the meal. Stimulation is not recommended; a quiet, unstimulating atmosphere should be maintained. Persistence during feeding may need to be implemented. Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Although forced feeding is avoided, “strictly encouraged” feeding is essential. The length of the feeding should be established (usually 30 minutes); limiting the feeding to 10 minutes would make the infant feel rushed.

 

DIF:    Cognitive Level: Apply                  REF:   p. 342

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap). Which should the nurse include in the instructions?
a. Shampoo every three days with a mild soap.
b. The hair should be shampooed with a medicated shampoo.
c. Shampoo every day with an antiseborrheic shampoo.
d. The loosened crusts should not be removed with a fine-toothed comb.

 

 

ANS:  C

When seborrheic lesions are present, the treatment is directed at removing the crusts. Parents are taught the appropriate procedure to clean the scalp. Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing.

 

DIF:    Cognitive Level: Apply                  REF:   p. 346

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been noted of which of the following pediatric disorders? (Select all that apply.)
a. SIDS
b. Torticollis
c. Failure to thrive
d. Apnea of infancy
e. Plagiocephaly

 

 

ANS:  B, E

Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull. If that side becomes misshapen, facial asymmetry may result. The sternocleidomastoid muscle may tighten on the affected side, causing torticollis. SIDS has decreased by more than 40% with the introduction of the Back to Sleep campaign. Apnea of infancy and failure to thrive are unrelated to the Back to Sleep campaign.

 

DIF:    Cognitive Level: Understand          REF:   p. 346

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant’s risk of a sudden infant death syndrome incident? (Select all that apply.)
a. Breastfeeding
b. Low Apgar scores
c. Male sex
d. Birth weight in the 50th or higher percentile
e. Recent viral illness

 

 

ANS:  B, C, E

Certain groups of infants are at increased risk for SIDS: low birth weight, low Apgar scores, recent viral illness, and male sex. Breastfed infants and infants of average or above average weight are not at higher risk for SIDS.

 

DIF:    Cognitive Level: Understand          REF:   p. 336

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. An infant has been diagnosed with cow’s milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
a. Pink mucous membranes
b. Vomiting
c. Rhinitis
d. Abdominal pain
e. Moist skin

 

 

ANS:  B, C, D

An infant with cow’s milk allergy will possibly have vomiting, rhinitis, and abdominal pain. The mucous membranes may be pale due to anemia from blood lost in the GI tract, and the skin will be itchy with the possibility of atopic dermatitis.

 

DIF:    Cognitive Level: Understand          REF:   p. 346

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant? (Select all that apply.)
a. Allow parents to say goodbye to their infant.
b. Once parents leave the hospital, no further follow-up is required.
c. Arrange for someone to take the parents home from the hospital.
d. Avoid requesting an autopsy of the deceased infant.
e. Conduct a debriefing session with the parents before they leave the hospital.

 

 

ANS:  A, C, E

An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say good-bye to their infant. These are the parents’ last moments with their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as possible. Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional should visit them after the death as soon as possible.

 

DIF:    Cognitive Level: Understand          REF:   p. 340

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Where do the lesions of atopic dermatitis (eczema) most commonly occur in the infant? (Select all that apply.)
a. Cheeks
b. Buttocks
c. Extensor surfaces of arms and legs
d. Back
e. Trunk
f. Scalp

 

 

ANS:  A, C, E, F

The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. The buttocks and back are not common locations for the lesions of atopic dermatitis in infants.

 

DIF:    Cognitive Level: Understand          REF:   p. 340

TOP:   Integrated Process: Nursing Process: Assessment

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

 

  1. The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema). Which response(s) should the nurse reinforce with the parent? (Select all that apply.)
a. “You can use warm wet compresses to relieve discomfort.”
b. “You will need to keep your infant’s skin well hydrated by using a mild soap in the bath.”
c. “You should bathe your baby in a bubble bath two times a day.”
d. “You will need to prevent your baby from scratching the area by using a mild antihistamine.”
e. “You can try a fabric softener in the laundry to avoid rough cloth.”
f. “You should apply an emollient to the skin immediately after a bath.”

 

 

ANS:  B, D, F

The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection; an antihistamine can be used. Keeping the skin hydrated is a goal of treating atopic dermatitis. Applying an emollient immediately after a bath helps to trap moisture and prevent moisture loss. Cool wet compresses should be used for relief. Bubble baths and harsh soaps should be avoided, as is bathing excessively, since this leads to drying. Fabric softener should be avoided because of the irritant effects of some of its components.

 

DIF:    Cognitive Level: Apply                  REF:   p. 340

TOP:   Integrated Process: Teaching/Learning

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

 

SHORT ANSWER

 

  1. An infant is having an anaphylactic reaction, and the nurse is preparing to administer epinephrine 0.001 mg/kg. The child weighs 22 pounds. What is the epinephrine dose the nurse should administer? (Record your answer using two decimal places.)

 

ANS:

0.01

 

Convert the 22 pounds to kilograms by dividing 22 by 2.2 = 10. Multiply the 10 by 0.001 mg of epinephrine = 0.01 mg as the dose to be given.

 

DIF:    Cognitive Level: Apply                  REF:   p. 334

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

OTHER

 

  1. A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).

 

  1. Call Jason’s parents and notify them of the situation.
  2. Call Jason’s family practitioner to obtain further orders for medication.
  3. Promptly administer an intramuscular dose of epinephrine.
  4. Call 911 and wait for the emergency response personnel to arrive.

 

ANS:

c, d, b, a

 

The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be contacted for further orders and, last, the parents notified of the situation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 350

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

Chapter 20: Pediatric Variations of Nursing Interventions

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

 

MULTIPLE CHOICE

 

  1. Which should the nurse consider when having consent forms signed for surgery and procedures on children?
a. Only a parent or legal guardian can give consent.
b. The person giving consent must be at least 18 years old.
c. The risks and benefits of a procedure are part of the consent process.
d. A mental age of 7 years or older is required for a consent to be considered “informed.”

 

 

ANS:  C

The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances, such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed.

 

DIF:    Cognitive Level: Understand          REF:   p. 575

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Safe and Effective Care Environment: Management of Care

 

  1. The nurse is planning to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include which action?
a. Plan for a short teaching session of about 30 minutes.
b. Tell the child that procedures are never a form of punishment.
c. Keep equipment out of the child’s view.
d. Use correct scientific and medical terminology in explanations.

 

 

ANS:  B

Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. Teaching sessions for this age group should be 10 to 15 minutes in length. Demonstrate the use of equipment, and allow the child to play with miniature or actual equipment. Explain procedure in simple terms and how it affects the child.

 

DIF:    Cognitive Level: Apply                  REF:   p. 575

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. What is the most appropriate nursing action?
a. Allow her to wear her underpants
b. Discuss with her mother why this is important to Katie
c. Ask her mother to explain to her why she cannot wear them
d. Explain in a kind, matter-of-fact manner that this is hospital policy

 

 

ANS:  A

It is appropriate for the child to leave her underpants on. This allows her some measure of control in this procedure, foot surgery. Further discussions may make the child more upset. Katie is too young to understand what hospital policy means.

 

DIF:    Cognitive Level: Apply                  REF:   p. 578

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Using knowledge of child development, which is the best approach when preparing a toddler for a procedure?
a. Avoid asking the child to make choices.
b. Demonstrate the procedure on a doll.
c. Plan for the teaching session to last about 20 minutes.
d. Show necessary equipment without allowing the child to handle it.

 

 

ANS:  B

Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child’s favorite doll because the toddler may think the doll is really “feeling” the procedure. In preparing a toddler for a procedure, allow the child to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment, and allow the child to handle it.

 

DIF:    Cognitive Level: Apply                  REF:   p. 578

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. The girl tells the nurse she wants her mother with her “like before.” What is the most appropriate nursing action?
a. Grant her request
b. Explain why this is not possible
c. Identify an appropriate substitute for her mother
d. Offer to provide support to her during the procedure

 

 

ANS:  A

The parent’s preferences for assisting, observing, or waiting outside the room should be assessed, along with the child’s preference for parental presence. The child’s choice should be respected. If the mother and child are agreeable, then the mother is welcome to stay. An appropriate substitute for the mother is necessary only if the mother does not wish to stay. Support is offered to the child regardless of parental presence.

 

DIF:    Cognitive Level: Apply                  REF:   p. 596

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The emergency department nurse is cleaning multiple facial abrasions on a 9-year-old child whose mother is present. The child is crying and screaming loudly. What is the best nursing action?
a. Ask the child to be quieter
b. Have the child’s mother give instructions about relaxation
c. Tell the child it is okay to cry and scream
d. Remove the mother from the room

 

 

ANS:  C

The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know it is all right to cry. There is no reason for the child to be quieter and feelings need to be able to be expressed. The mother should stay in the room to provide comfort to the child.

 

DIF:    Cognitive Level: Apply                  REF:   p. 577

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, what is an early sign of this disorder?
a. Apnea
b. Bradycardia
c. Muscle rigidity
d. Decreased blood pressure

 

 

ANS:  C

Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia. Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased blood pressure, not decreased blood pressure, is characteristic of malignant hyperthermia.

 

DIF:    Cognitive Level: Understand          REF:   p. 583

TOP:   Integrated Process: Nursing Process: Assessment

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

 

  1. The nurse is caring for an unconscious child. Skin care should include which action?
a. Avoid use of pressure reduction on bed.
b. Massage reddened bony prominences to prevent deep tissue damage.
c. Use draw sheet to move child in bed to reduce friction and shearing injuries.
d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

 

 

ANS:  C

A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms. Pressure-reduction devices should be used to redistribute weight. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices should be used instead. The skin should be cleansed with mild non-alkaline soap or soap-free cleaning agents for routine bathing.

 

DIF:    Cognitive Level: Apply                  REF:   p. 586

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. What is an appropriate intervention to encourage food and fluid intake in a hospitalized child?
a. Force the child to eat and drink to combat caloric losses.
b. Discourage participation in non-eating activities until caloric intake is sufficient.
c. Administer large quantities of flavored fluids at frequent intervals and during meals.
d. Give high-quality foods and snacks whenever the child expresses hunger.

 

 

ANS:  D

Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the behavior as a control mechanism. Large quantities of fluid may decrease the child’s hunger and further inhibit food intake.

 

DIF:    Cognitive Level: Apply                  REF:   p. 588

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his “regular diet” trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action?
a. Request these favorite foods for him.
b. Identify healthier food choices that he likes.
c. Explain that he needs fruits and vegetables.
d. Reward him with ice cream at the end of every meal that he eats.

 

 

ANS:  A

Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, favorite foods should be requested for the child. These foods provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

 

DIF:    Cognitive Level: Apply                  REF:   p. 608

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A 3-year-old child has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse’s action should be based on which statement?
a. Fevers such as this are common with viral illnesses.
b. Seizures are common in children when antipyretics are ineffective.
c. Fever over 102° F indicates greater severity of illness.
d. Fever over 102° F indicates a probable bacterial infection.

 

 

ANS:  A

Most fevers are of brief duration, with limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection.

 

DIF:    Cognitive Level: Apply                  REF:   p. 589

TOP:   Integrated Process: Teaching/Learning

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

 

  1. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). What should the nurse explain about antipyretics?
a. They may cause malignant hyperthermia
b. They may cause febrile seizures
c. They are of no value in treating hyperthermia
d. They are of limited value in treating hyperthermia

 

 

ANS:  C

Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics do not cause seizures and are of no value in hyperthermia.

 

DIF:    Cognitive Level: Apply                  REF:   p. 589

TOP:   Integrated Process: Teaching/Learning

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

 

  1. Tepid water or sponge baths are indicated for hyperthermia in children. What is the priority nursing action?
a. Add isopropyl alcohol to the water.
b. Direct a fan on the child in the bath.
c. Stop the bath if the child begins to chill.
d. Continue the bath for 5 minutes.

 

 

ANS:  C

Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the body’s way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever. Ice water and isopropyl alcohol are potentially dangerous solutions. Fans should not be used because of the risk of the child developing vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to the skin surface, and the blood remains primarily in the viscera to become heated. The child is placed in a tub of tepid water for 20 to 30 minutes.

 

DIF:    Cognitive Level: Apply                  REF:   p. 589

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. The nurse approaches a group of school-age patients to administer medication to Sam Hart. What should the nurse do to identify the correct child?
a. Ask the group, “Who is Sam Hart?”
b. Call out to the group, “Sam Hart?”
c. Ask each child, “What’s your name?”
d. Check the patient’s identification name band

 

 

ANS:  D

The child must be correctly identified before the administration of any medication. Children are not totally reliable in giving correct names on request; the identification bracelet should always be checked. Asking children or the group for names is not an acceptable way to identify a child. Older children may exchange places, give an erroneous name, or choose not to respond to their name as a joke.

 

DIF:    Cognitive Level: Apply                  REF:   p. 608

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. The nurse wore gloves during a dressing change. What should the nurse do after the gloves are removed?
a. Wash hands thoroughly
b. Check the gloves for leaks
c. Rinse gloves in disinfectant solution
d. Apply new gloves before touching the next patient

 

 

ANS:  A

When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of after use. Hands should be thoroughly washed before new gloves are applied.

 

DIF:    Cognitive Level: Apply                  REF:   p. 612

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. The nurse gives an injection in a patient’s room. The nurse should perform which intervention with the needle for disposal?
a. Dispose of syringe and needle in a rigid, puncture-resistant container in the patient’s room.
b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of the patient’s room.
c. Cap needle immediately after giving injection and dispose of in a proper container.
d. Cap needle, break from syringe, and dispose of in a proper container.

 

 

ANS:  A

All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently, these containers should be installed in the patient’s room. The uncapped needle should not be transported to an area distant from use. Needles are disposed of uncapped and unbroken.

 

DIF:    Cognitive Level: Apply                  REF:   p. 590

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A mother calls the outpatient clinic requesting information on appropriate dosing for over-the-counter medications for her 13-month-old who has symptoms of an upper respiratory tract infection and fever. The box of acetaminophen says to give 120 mg q4h when needed. At his 12-month visit, the nurse practitioner prescribed 150 mg. What is the nurse’s best response?
a. “The doses are close enough; it doesn’t really matter which one is given.”
b. “It is not appropriate to use dosages based on age because children have a wide range of weights at different ages.”
c. “From your description, medications are not necessary. They should be avoided in children at this age.”
d. “The nurse practitioner ordered the drug based on weight, which is a more accurate way of determining a therapeutic dose.”

 

 

ANS:  D

The method most often used to determine children’s dosage is based on a specific dose per kilogram of body weight. The mother should be given correct information. For a therapeutic effect, the dosage should be based on weight, not age. Acetaminophen can be used to relieve discomfort in children at this age group.

 

DIF:    Cognitive Level: Apply                  REF:   p. 589

TOP:   Integrated Process: Teaching/Learning

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

 

  1. An 8-month-old infant is restrained to prevent interference with the IV infusion. How should the nurse appropriately care for this child?
a. Remove the restraints once a day to allow movement.
b. Keep the restraints on constantly.
c. Keep the restraints secure so the infant remains supine.
d. Remove restraints whenever possible.

 

 

ANS:  D

The nurse should remove the restraints whenever possible. When parents or staff are present, the restraints can be removed and the IV site protected. Restraints must be checked and documented every 1 to 2 hours. They should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.

 

DIF:    Cognitive Level: Apply                  REF:   p. 600

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. What information should the nurse include in her response to the child?
a. It is unsafe.
b. It is helpful to relax the child.
c. It is against hospital policy.
d. It is unnecessary because of child’s age.

 

 

ANS:  B

The mother’s preference for assisting, observing, or waiting outside the room should be assessed along with the child’s preference for parental presence. The child’s choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care. The child should determine whether parental support is necessary.

 

DIF:    Cognitive Level: Understand          REF:   p. 600

TOP:   Integrated Process: Nursing Process: Planning

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

 

  1. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what is the nurse’s best action?
a. Prepare child for conscious sedation during the test.
b. Set up a tray with equipment the same size as for adults.
c. Reassure the parents that the test is simple, painless, and risk free.
d. Apply EMLA to the puncture site 15 minutes before the procedure.

 

 

ANS:  A

Because of the urgency of the child’s condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. Reassuring the parents that the test is simple, painless, and risk free is incorrect information. A spinal tap does have associated risks, and analgesia will be given for the pain. EMLA (a eutectic mixture of anesthetics) should be applied approximately 60 minutes before the procedure. The emergency nature of the spinal tap precludes its use.

 

DIF:    Cognitive Level: Analyze               REF:   p. 596

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. Which is the most appropriate way to collect small amounts of urine for these tests?
a. Apply a urine-collection bag to the perineal area.
b. Tape a small medicine cup to the inside of the diaper.
c. Aspirate urine from cotton balls inside the diaper with a syringe.
d. Aspirate urine from a superabsorbent disposable diaper with a syringe.

 

 

ANS:  C

To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child’s skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.

 

DIF:    Cognitive Level: Apply                  REF:   p. 597

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. Which is an important nursing consideration when performing a bladder catheterization on a young boy?
a. Clean technique, not standard precautions, is needed.
b. Insert 2% lidocaine lubricant into the urethra.
c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly.
d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

 

 

ANS:  B

The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparation of the child and parents, by selection of the correct catheter, and by appropriate technique of insertion. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. Catheterization is a sterile procedure, and standard precautions for body-substance protection should be followed. Water-soluble lubricants do not provide appropriate local anesthesia. Catheterization should be delayed 2 to 3 minutes only. This provides sufficient local anesthesia for the procedure.

 

DIF:    Cognitive Level: Apply                  REF:   p. 597

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. The Allen test is performed as a precautionary measure before which procedure?
a. Heel stick
b. Venipuncture
c. Arterial puncture
d. Lumbar puncture

 

 

ANS:  C

The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or lumbar punctures.

 

DIF:    Cognitive Level: Understand          REF:   p. 601

TOP:   Integrated Process: Nursing Process: Assessment

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

 

  1. The nurse must do a heel stick on an ill neonate to obtain a blood sample. What action is recommended to facilitate blood flow?
a. Apply cool, moist compresses.
b. Apply a tourniquet to the ankle.
c. Elevate the foot for 5 minutes.
d. Wrap the foot in a warm washcloth.

 

 

ANS:  D

Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood collection more difficult. A tourniquet is used to constrict superficial veins. It will have an insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot available for collection.

 

DIF:    Cognitive Level: Understand          REF:   p. 601

TOP:   Integrated Process: Nursing Process: Assessment

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

 

  1. The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next?
a. Keep the arm extended while applying a bandage to the site.
b. Keep the arm extended, and apply pressure to the site for a few minutes.
c. Apply a bandage to the site, and keep the arm flexed for 10 minutes.
d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.

 

 

ANS:  B

Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before bandage is applied.

 

DIF:    Cognitive Level: Apply                  REF:   p. 601

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A nurse must do a venipuncture on a 6-year-old child. What is an important consideration in providing atraumatic care?
a. Use an 18-gauge needle if possible.
b. If not successful after four attempts, have another nurse try.
c. Restrain the child only as needed to perform venipuncture safely.
d. Show the child equipment to be used before the procedure.

 

 

ANS:  C

Restrain the child only as needed to perform the procedure safely; use therapeutic hugging. Use the smallest-gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Keep all equipment out of sight until used.

 

DIF:    Cognitive Level: Apply                  REF:   p. 601

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. What is an appropriate method for administering oral medications that are bitter to an infant or small child?
a. Mix in a bottle of formula or milk.
b. Mix with any food the child is going to eat.
c. Mix with a small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream.
d. Mix with large amounts of water to dilute medication sufficiently.

 

 

ANS:  C

Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat in the future.

 

DIF:    Cognitive Level: Apply                  REF:   p. 619

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration?
a. Administer the medication with a syringe (without needle) placed along the side of the infant’s tongue.
b. Administer the medication as rapidly as possible with the infant securely restrained.
c. Mix the medication with the infant’s regular formula or juice and administer by bottle.
d. Keep the child upright with the nasal passages blocked for a minute after administration.

 

 

ANS:  A

Administer the medication with a syringe without needle placed along the side of the infant’s tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. Holding the child’s nasal passages will increase the risk of aspiration.

 

DIF:    Cognitive Level: Apply                  REF:   p. 619

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. Which is the preferred site for intramuscular injections in infants?
a. Deltoid
b. Dorsogluteal
c. Rectus femoris
d. Vastus lateralis

 

 

ANS:  D

The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older children and adults. The rectus femoris is not a recommended site.

 

DIF:    Cognitive Level: Understand          REF:   p. 607

TOP:   Integrated Process: Nursing Process: Planning

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

 

  1. Guidelines for intramuscular administration of medication in school-age children include which action?
a. Inject medication as rapidly as possible.
b. Insert needle quickly, using a dart like motion.
c. Penetrate skin immediately after cleansing site, before skin has dried.
d. Have child stand, if possible, and if child is cooperative.

 

 

ANS:  B

The needle should be inserted quickly in a dart like motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before skin is penetrated. Place child in lying or sitting position.

 

DIF:    Cognitive Level: Apply                  REF:   p. 607

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. Several types of long-term central venous access devices are used. Which is considered an advantage of a Hickman-Broviac catheter?
a. No need to keep exit site dry
b. Easy to use for self-administered infusions
c. Heparinized only monthly and after each infusion
d. No limitations on regular physical activity, including swimming

 

 

ANS:  B

The Hickman-Broviac catheter has several benefits, including that it is easy to use for self-administered infusions. The exit site must be kept dry to decrease risk of infection. The Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted because of risk of infection.

 

DIF:    Cognitive Level: Understand          REF:   p. 611

TOP:   Integrated Process: Nursing Process: Planning

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

 

  1. When teaching a mother how to administer eye drops, where should the nurse tell her to place them?
a. In the conjunctival sac that is formed when the lower lid is pulled down
b. Carefully under the eye lid while it is gently pulled upward
c. On the sclera while the child looks to the side
d. Anywhere as long as drops contact the eye’s surface

 

 

ANS:  A

The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball.

 

DIF:    Cognitive Level: Understand          REF:   p. 617

TOP:   Integrated Process: Teaching/Learning

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

 

  1. A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. Which best explains why an intraosseous infusion is started?
a. It is less painful for small children.
b. Rapid venous access is not possible.
c. Antibiotics must be started immediately.
d. Long-term central venous access is not possible.

 

 

ANS:  B

In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local anesthetics and systemic analgesics are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time-consuming, and intraosseous infusion is used in an emergency situation.

 

DIF:    Cognitive Level: Analyze               REF:   p. 612

TOP:   Integrated Process: Nursing Process: Evaluation

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

 

  1. What should the nurse do when caring for a child with an intravenous infusion?
a. Use a macrodropper to facilitate reaching the prescribed flow rate.
b. Avoid restraining the child to prevent undue emotional stress.
c. Change the insertion site every 24 hours.
d. Observe the insertion site frequently for signs of infiltration.

 

 

ANS:  D

The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently (at least every 1 to 2 hours) to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. A minidropper (60 drops/ml) is the recommended IV tubing in pediatrics. The IV site should be protected. This may require soft restraints on the child. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma.

 

DIF:    Cognitive Level: Apply                  REF:   p. 615

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. What is a nursing consideration related to the administration of oxygen in an infant?
a. Humidify oxygen if the infant can tolerate it.
b. Assess the infant to determine how much oxygen should be given.
c. Ensure uninterrupted delivery of the appropriate oxygen concentration.
d. Direct oxygen flow so that it blows directly into the infant’s face in a hood.

 

 

ANS:  C

Oxygen is a prescribed medication. It is the nurse’s responsibility to ensure that the ordered concentration is delivered and the effects of therapy are monitored. Oxygen is drying to the tissues. Oxygen should always be humidified when delivered to a patient. A child receiving oxygen therapy should have the oxygen saturation monitored at least as frequently as vital signs. Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage as indicated. Humidified oxygen should not be blown directly into an infant’s face.

 

DIF:    Cognitive Level: Understand          REF:   p. 325

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. It is important to make certain that sensory connectors and oximeters are compatible. What can incompatible wiring cause?
a. Hyperthermia
b. Electrocution
c. Pressure necrosis
d. Burns under sensors

 

 

ANS:  D

It is important to make certain that sensor connectors and oximeters are compatible. Wiring that is incompatible can generate considerable heat at the tip of the sensor, causing second- and third-degree burns under the sensor. Incompatibility would cause a local irritation or burn. A low voltage is used, which should not present risk of electrocution. Pressure necrosis can occur from the sensor being attached too tightly, but this is not a problem of incompatibility.

 

DIF:    Cognitive Level: Understand          REF:   p. 626

TOP:   Integrated Process: Nursing Process: Assessment

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

 

  1. The nurse is teaching a mother how to perform chest physical therapy and postural drainage on her 3-year-old child, who has cystic fibrosis. How should the nurse instruct the mother?
a. Cover the skin with a shirt or gown before percussing.
b. Strike the chest wall with a flat-hand position.
c. Percuss over the entire trunk anteriorly and posteriorly.
d. Percuss before positioning for postural drainage.

 

 

ANS:  A

For postural drainage and percussion, the child should be dressed in a light shirt to protect the skin and placed in the appropriate postural drainage positions. The chest wall is struck with a cupped-hand, not a flat-hand position. The procedure should be done over the rib cage only. Positioning precedes the percussion.

 

DIF:    Cognitive Level: Apply                  REF:   p. 627

TOP:   Integrated Process: Teaching/Learning

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

 

  1. The nurse must suction a child with a tracheostomy. What is the appropriate technique?
a. Encourage the child to cough to raise the secretions before suctioning.
b. Select a catheter with diameter three-fourths as large as the diameter of the tracheostomy tube.
c. Ensure each pass of the suction catheter should take no longer than 5 seconds.
d. Allow the child to rest after every five times the suction catheter is passed.

 

 

ANS:  C

Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be occluded for too long. If the child is able to cough up secretions, suctioning may not be indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it is too large, it might block the child’s airway. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear.

 

DIF:    Cognitive Level: Apply                  REF:   p. 628

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. How should the nurse administer a gavage feeding to a school-age child?
a. Lubricate the tip of the feeding tube with Vaseline to facilitate passage.
b. Check the placement of the tube by inserting 20 ml of sterile water.
c. Administer feedings over 5 to 10 minutes.
d. Position the patient on the right side after administering feeding.

 

 

ANS:  D

Position the child with the head elevated about 30 degrees and on the right side or abdomen for at least 1 hour. This is in the same manner as after any infant feeding to minimize the possibility of regurgitation and aspiration. Insert a tube that has been lubricated with sterile water or water-soluble lubricant. With a syringe, inject a small amount of air into the tube, while simultaneously listening with a stethoscope over the stomach area. Feedings should be administered via gravity flow and take from 15 to 30 minutes to complete.

 

DIF:    Cognitive Level: Apply                  REF:   p. 594

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 ml/8 hr is being infused rather than the ordered amount of 300 ml/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours?
a. 200 ml
b. 300 ml
c. 350 ml
d. 400 ml

 

 

ANS:  B

The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.

 

DIF:    Cognitive Level: Apply                  REF:   p. 610

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. In preparing to give “enemas until clear” to a young child, the nurse should select which solution?
a. Tap water
b. Normal saline
c. Oil retention
d. Fleet solution

 

 

ANS:  B

Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the “until clear” result. Fleet enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the Fleet enema can result in diarrhea, which can lead to metabolic acidosis.

 

DIF:    Cognitive Level: Apply                  REF:   p. 624

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. The nurse is doing a pre-hospitalization orientation for a 7-year-old child who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is:
a. unnecessary.
b. the surgeon’s responsibility.
c. too stressful for a young child.
d. an appropriate part of the child’s preparation.

 

 

ANS:  D

Explanation is a necessary part of preoperative preparation. If the child wakes and is not prepared for the inability to speak, she will be even more anxious. This is a necessary component for preparation for surgery that will help reduce the anxiety associated with surgery. It is a joint responsibility of nursing, medical staff, and child life personnel.

 

DIF:    Cognitive Level: Analyze               REF:   p. 584

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The advantages of the ventrogluteal muscle as an injection site in young children include which considerations? (Select all that apply.)
a. Less painful than vastus lateralis
b. Free of important nerves and vascular structures
c. Cannot be used when child reaches a weight of 20 pounds
d. Increased subcutaneous fat, which increases drug absorption
e. Easily identified by major landmarks

 

 

ANS:  A, B, E

The advantages of the ventrogluteal are being less painful, free of important nerves and vascular lateralis, and easily identified by major landmarks. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The use of the ventrogluteal has not been clarified. It has been used in infants, but clinical guidelines address the need for the child to be walking, thus generally being over 20 pounds. The site has less subcutaneous tissue, which facilitates intramuscular (rather than subcutaneous) deposition of the drug.

 

DIF:    Cognitive Level: Understand          REF:   p. 605

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A nurse is caring for a child in droplet precautions. Which instructions should the nurse give to the unlicensed assistive personnel caring for this child? (Select all that apply.)
a. Wear gloves when entering the room.
b. Wear an isolation gown when entering the room.
c. Place the child in a special air handling and ventilation room.
d. A mask should be worn only when holding the child.
e. Wash your hands upon exiting the room.

 

 

ANS:  A, B, E

Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during procedures such as suctioning and bronchoscopy. Gloves, gowns, and a mask should be worn when entering the room. Hand washing when exiting the room should be done with any patient. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission.

 

DIF:    Cognitive Level: Apply                  REF:   p. 591

TOP:   Integrated Process: Nursing Process: Implementation

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

 

COMPLETION

 

  1. A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin). The dosage is 0.07 mg/kg/day, and the child’s weight is 7.2 kg. The physician prescribes the digoxin to be given once a day by mouth. Each dose will be _____ milligrams. (Record your answer below using one decimal place.)

 

ANS:

0.5

 

Calculate the dosage by weight: 0.07 mg/day ´ 7.2 kg = 0.5 mg/day.

 

DIF:    Cognitive Level: Analyze               REF:   p. 585

TOP:   Integrated Process: Nursing Process: Implementation

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

 

  1. A physician’s prescription reads, “ampicillin sodium 125 mg IV every 6 hours.” The medication label reads, “1 g = 7.4 ml.” A nurse prepares to draw up _____ milliliters to administer one dose. (Round your answer to two decimal places.)

 

ANS:

0.93

 

Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point three places to the right.

1 g = 1000 mg

Formula:

Desired ´ Volume = 125 mg/1000 mg ´ 7.4 ml = 0.925 round to 0.93 ml.

Available

 

DIF:    Cognitive Level: Analyze               REF:   p. 619

TOP:   Integrated Process: Nursing Process: Implementation

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

 

SHORT ANSWER

 

  1. A 6-month-old infant is admitted to the pediatric unit with respiratory syncytial virus (RSV). The nurse places the infant on strict intake and output. The infant is in a size #2 diaper and the dry weight is 24 g. At the end of the shift, the infant has had two diapers with urine. One diaper weighed 56 g and one weighed 65 g. What is the total milliliter output for the shift? (Record your answer as a whole number below.)

 

ANS:

73

 

1 g of wet diaper weight = 1 ml of urine.

The dry weight of the diaper is 24 g.

56 g – 24 g = 32 ml.

65 g – 24 g = 41 ml.

32 ml + 24 ml = 73 ml total output for the shift.

 

DIF:    Cognitive Level: Apply                  REF:   p. 602

TOP:   Integrated Process: Nursing Process: Implementation

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

 

OTHER

 

  1. The nurse is preparing to insert a nasogastric tube into a 4-year-old child for intermittent suctioning after abdominal surgery. Place in correct sequence the steps for inserting a nasogastric tube. Provide the answer using lowercase letters separated by commas (e.g., a, b, c, d, e, f).

 

  1. Lubricate the nasogastric tube with water-soluble lubricant.
  2. Tape the nasogastric tube securely to the child’s face.
  3. Check the placement of the tube by aspirating stomach contents.
  4. Place the child in the supine position with head slightly hyperflexed.
  5. Insert the nasogastric tube through the nares.
  6. Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid process and the umbilicus.

 

ANS:

d, f, a, e, c, b

 

DIF:    Cognitive Level: Remember           REF:   p. 621

TOP:   Integrated Process: Nursing Process: Implementation

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

 

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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