Pediatric Nursing The Critical Components of Nursing Care Edition 2nd Rudd Bank Test ,100% CORRECT

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Pediatric Nursing The Critical Components of Nursing Care Edition 2nd Rudd Bank Test Chapter 1. Issues and Trends in Pediatric Nursing MULTIPLE CHOICE 1. A nurse is reviewing changes in healthca... re delivery and funding for pediatric populations. Which current trend in the pediatric setting should the nurse expect to find? a. Increased hospitalization of children b. Decreased number of uninsured children c. An increase in ambulatory care d. Decreased use of managed care ANS: C One effect of managed care is that pediatric healthcare delivery has shifted dramatically from the acute care setting to the ambulatory setting. The number of hospital beds being used has decreased as more care is provided in outpatient and home settings. The number of uninsured children in the United States continues to grow. One of the biggest changes in healthcare has been the growth of managed care. DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 2. A nurse is referring a low-income family with three children under the age of 5 years to a program that assists with supplemental food supplies. Which program should the nurse refer this family to? a. Medicaid b. Medicare c. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program d. Women, Infants, and Children (WIC) program ANS: D WIC is a federal program that provides supplemental food supplies to low-income women who are pregnant or breast-feeding and to their children until the age of 5 years. Medicaid and the Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program provides for well-child examinations and related treatment of medical problems. Children in the WIC program are often referred for immunizations, but that is not the primary focus of the program. Public Law 99-457 provides financial incentives to states to establish comprehensive early intervention services for infants and toddlers with, or at risk for, developmental disabilities. Medicare is the program for Senior Citizens. DIF: Cognitive Level: Application REF: p. 7 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 3. In most states, adolescents who are not emancipated minors must have parental permission before: a. treatment for drug abuse. b. treatment for sexually transmitted diseases (STDs). c. obtaining birth control. d. surgery. ANS: D An emancipated minor is a minor child who has the legal competence of an adult. Legal counsel may be consulted to verify the status of the emancipated minor for consent purposes. Most states allow minors to obtain treatment for drug or alcohol abuse and STDs and allow access to birth control without parental consent. DIF: Cognitive Level: Application REF: p. 12 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 4. A nurse is completing a clinical pathway for a child admitted to the hospital with pneumonia. Which characteristic of a clinical pathway is correct? a. Developed and implemented by nurses b. Used primarily in the pediatric setting c. Specific time lines for sequencing interventions d. One of the steps in the nursing process ANS: C Clinical pathways measure outcomes of client care and are developed by multiple healthcare professionals. Each pathway outlines specific time lines for sequencing interventions and reflects interdisciplinary interventions. Clinical pathways are used in multiple settings and for clients throughout the life span. The steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 5. When planning a parenting class, the nurse should explain that the leading cause of death in children 1 to 4 years of age in the United States is: a. premature birth. b. congenital anomalies. c. accidental death. d. respiratory tract illness. ANS: C Accidents are the leading cause of death in children ages 1 to 19 years. Disorders of short gestation and unspecified low birth weight make up one of the leading causes of death in neonates. One of the leading causes of infant death after the first month of life is congenital anomalies. Respiratory tract illnesses are a major cause of morbidity in children. DIF: Cognitive Level: Application REF: p. 9 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 6. Which statement is true regarding the quality assurance or incident report? a. The report assures the legal department that there is no problem. b. Reports are a permanent part of the clients chart. c. The nurses notes should contain the following: Incident report filed and copy placed in chart. d. This report is a form of documentation of an event that may result in legal action. ANS: D An incident report is a warning to the legal department to be prepared for potential legal action; it is not a part of the clients chart or nurse documentation. DIF: Cognitive Level: Knowledge REF: p. 14 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 7. Which client situation fails to meet the first requirement of informed consent? a. The parent does not understand the physicians explanations. b. The physician gives the parent only a partial list of possible side effects and complications. c. No parent is available and the physician asks the adolescent to sign the consent form. d. The infants teenage mother signs a consent form because her parent tells her to. ANS: C The first requirement of informed consent is that the person giving consent must be competent. Minors are not allowed to give consent. An understanding of information, full disclosure, and voluntary consent are requirements of informed consent, but none of these is the first requirement. DIF: Cognitive Level: Comprehension REF: p. 12 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 8. A nurse assigned to a child does not know how to perform a treatment that has been prescribed for the child. What should the nurses first action be? a. Delay the treatment until another nurse can do it. b. Make the childs parents aware of the situation. c. Inform the nursing supervisor of the problem. d. Arrange to have the child transferred to another unit. ANS: C If a nurse is not competent to perform a particular nursing task, the nurse must immediately communicate this fact to the nursing supervisor or physician. The nurse could endanger the child by delaying the intervention until another nurse is available. Telling the childs parents would most likely increase their anxiety and will not resolve the difficulty. Transfer to another unit delays needed treatment and would create unnecessary disruption for the child and family. DIF: Cognitive Level: Application REF: p. 11 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 9. A nurse is completing a care plan for a child and is finishing the assessment phase. Which activity is not part of a nursing assessment? a. Writing nursing diagnoses b. Reviewing diagnostic reports c. Collecting data d. Setting priorities ANS: D Setting priorities is a part of planning. Writing nursing diagnoses, reviewing diagnostic reports, and collecting data are parts of assessment. DIF: Cognitive Level: Comprehension REF: p. 19 OBJ: Nursing Process Step: Planning MSC: Physiological Integrity 10. Which patient outcome is stated correctly? a. The child will administer his insulin injection before breakfast on 10/31. b. The child will accept the diagnosis of type 1 diabetes mellitus before discharge. c. The parents will understand how to determine the childs daily insulin dosage. d. The nurse will monitor blood glucose levels before meals and at bedtime. ANS: A The outcome is stated in client terms, with a measurable verb and a time frame for action. The verb accept is difficult to measure. The goal of accepting a diagnosis before hospital discharge is unrealistic. Outcomes should be stated in client terms. Nursing actions are determined after outcomes are developed in the implementation phase of the nursing process. DIF: Cognitive Level: Application REF: p. 20 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment MULTIPLE RESPONSE 1. A nurse is reviewing the nursing care plan for a hospitalized child. Which statements are collaborative problems? Select all that apply. a. Risk for injury b. Potential complication of seizure disorder c. Altered nutrition: Less than body requirements d. Fluid volume deficit e. Potential complication of respiratory acidosis ANS: B, E In addition to nursing diagnoses, which describe problems that respond to independent nursing functions, nurses must also deal with problems that are beyond the scope of independent nursing practice. These are sometimes termed collaborative problemsphysiological complications that usually occur in association with a specific pathological condition or treatment. The potential complications of seizure disorder and respiratory acidosis are physiological complications that will require physician collaboration to treat. Risk for injury, altered nutrition, and fluid volume deficit will respond to independent nursing functions. DIF: Cognitive Level: Application REF: p. 20 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 2. Which nursing activities do not meet the standard of care? Select all that apply. a. Failure to notify a physician about a childs worsening condition b. Calling the supervisor about staffing concerns c. Delegating assessment of a new admit to the Unlicensed Assistive Personnel (UAP) d. Asking the Unlicensed Assistive Personnel (UAP) to take vital signs e. Documenting that a physician was unavailable and the nursing supervisor was notified ANS: A, C A nurse who fails to notify a physician about a childs worsening condition and delegating the assessment of a new admit to a UAP do not meet the standard of care. Calling the supervisor about staffing concerns, asking the UAP to take vital signs, and documenting that a physician could not be reached and the nursing supervisor was notified all meet the standard of care. Chapter 2. Standards of Practice and Ethical Considerations Multiple Choice 1. Leah is a new graduate nurse and has questions about her scope of practice. The best place to review would be: 1. The code of ethics. 2. The standards of practice and professional performance. 3. The NCLEX exam. 4. The state licensing body. ANS: 2 Feedback 1.Applies to the accountability and protection for the public 2.Benchmark for quality and accountability to provide professional guidance 3.This is the basic exam, but it does not give guidance on this matter. 4.The state has rules and regulations, but it is not the source for overall professional accountability and guidance. 2. The Code of Ethics for Nurses is characterized by all of the following except: 1. It serves as a guide to empower individuals. 2. It upholds ethics, principles, rights, duties and virtues. 3. It is a private statement for nurses only. 4. It is a public statement for nurses and their patients. ANS: 3 Feedback 1.Part of the Code of Ethics 2.Part of the Code of Ethics 3. The Code of Ethics is not a private statement. It is for the public and nurses. 4. Part of the Code of Ethics 3. A nurse has discussed the plan of care, asked for parental input, and has spoken with the doctor about the needs of the family and patient. This nurse is exhibiting which characteristics of therapeutic relationships in pediatric medicine? 1. Goals, mutual respect/trust, and advocacy 2. Empowerment, sympathy, and empathy 3. Goals, advocacy, and sympathy 4. Respect/trust, disengagement, and sympathy ANS: 1 Feedback 1. The nurse is demonstrating all characteristics listed. 2. The nurse is not demonstrating sympathy or empathy for the patient. 3.The nurse is not demonstrating sympathy for this family. 4.The nurse is not disengaging or providing sympathy for the family. 4. A primary source for the standards of practice for pediatric nurses is: 1. Pediatric Nursing Scope and Standards of Practice. 2. Code of Ethics. 3. Nightingales Pledge. 4. None of the above. ANS: 1 Feedback 1. Reflects key themes and trends that are relevant to our time and to all pediatric health care settings, which provide the framework for the emergence of specific standards. 2. The Code of Ethics in Nursing provides a foundation for nurses and empowers them as well. 3. The pledge was part of the early Hippocratic Oath. 4.One answer is correct. 5. Sarah is a 4-year-old patient with cystic fibrosis. She has been having increased hospitalizations and prefers to have Leah as her nurse as an inpatient. Leah has been assigned to care for a different set of patients today, yet Sarahs mother insists on having Leah as their nurse. Which action would be best for Leah to take with Sarah and her mother? 1. Ignore the situation. 2. Speak to Sarah and her mother to discuss the importance of having another nurse, who also knows the case, care for her. 3. Let Sarahs mother and Sarah voice their reasoning for wanting Leah, and then explain the need for Leah to have a different assignment. 4. Let the charge nurse deal with the situation. ANS: 3 Feedback 1.Ignoring the situation does not demonstrate therapeutic communication. 2.Speaking with the family is important, but letting the family voice their concerns is important as well. 3. The dialogue between the patient and nurse can enhance trust and understanding so the patient can understand the situation. 4. The charge nurse may be part of the conversation, but it is important for Leah to speak too. 6. Which of the following situations would be considered a therapeutic communication challenge in pediatric nursing? 1. 1. A street-smart teenager 2. 2. A noncompliant patient and family 3. 3. A culture that the nurse has not been previously exposed to 4. 4. All of the above ANS: 4 Feedback 1.Considered a therapeutic communication challenge in pediatric nursing 2.Considered a therapeutic communication challenge in pediatric nursing 3.Considered a therapeutic communication challenge in pediatric nursing 4.All fit the criteria 7. The purpose of a Child Life Department for Family-Centered Care is: 1. To prepare the child for procedures. 2. To offer time to be a kid. 3. To provide the staff with information about child development. 4. To be the liaison between the hospital and the school system for a child. 5. 1, 2, 4 ANS: 5 Feedback 1. Preparation is an important element in caring for a child. It helps reduce anxiety and promotes a trusting relationship. 2. Playtime allows a child to cope and fosters self-expression, which reduces stress. 3. CLD is knowledgeable in child development and is present to support the child and the family, not the staff. 4. CLD provides a working relationship between the hospital and school for patients who are in the hospital long term. 5. Preparation is an important element in caring for a child. It helps reduce anxiety and promotes a trusting relationship. Playtime allows a child to cope and fosters self-expression, which reduces stress. CLD provides a working relationship between the hospital and school for patients who are in the hospital long term. 8. A nurse is discussing pain management of a 3 year-old with the parents. An important factor the nurse should mention is: 1. A child is like a mini-adult, so they cope with pain the same way. 2. Effective pain management for a child may require pharmacological and non-pharmacological methods. 3. Children use the pain scale of 0-10. 4. Pain is subjective, and all children cry when they are in pain. ANS: 2 Feedback 1. Children have a unique response to pain. 2. Pharmacological methods may work for children, but using non- pharmacological methods, such as distraction, are also beneficial. 3. Common pain scales for children consist of the FLACC and NAP. 4.Pain is subjective, but not all children will cry. Some will be irritable or withdrawn. 9. A 6-year-old boy is to receive a dose of morphine to aid in pain management after an open appendectomy. The nurse knows the correct dose for the morphine is calculated based on: 1. Age. 2. Height. 3. Body weight. 4. All of the above. ANS: 3 Feedback 1. Age is not a factor in drug calculation. 2. Height is not a factor in drug calculation. 3. Body weight is used for drug calculation. 4. Age and height do not affect drug calculation. 10. A nurse at the clinic is teaching a new mother how to give Tylenol drops to her infant. The nurse knows that the mother has an understanding of medication administration when the mother states: 1. I will give the medication as prescribed and use a teaspoon to measure the correct amount. 2. I will use a syringe to measure the correct amount and place the syringe in the side of his cheek to take the medicine. 3. I will measure the medication in a cup and place it into the bottle. 4. I will make sure he only takes the medicine until he acts like he feels better. ANS: 2 Feedback 1.A teaspoon does not give an accurate measurement for childrens medication. 2.A syringe is the best option for medication administration. Placing it in the side of the cheek enables the infant to swallow without choking. 3. This method does not ensure that the child received all the medication, especially if the entire bottle is not consumed. 4. Medication should be taken for as long as the doctor has ordered. 11. The public health nurse is working on new printed material for the pediatric clinic. The public health nurse decides more education needs to be provided on nutritious snacks for children 5 to 10 years of age. In the design process of the pamphlets, it is important for the public health nurse to: 1. Provide information at an educational level no higher than 8th grade. 2. Provide information at an education level no higher than 12th grade. 3. Provide the material in an easy manner, using acronyms to keep the pamphlet small. 4. Provide information in small print and place the pamphlet in open areas for people to take freely. ANS: 1 Feedback 1.Information should be at the 8th grade level or lower. 2.Information should be at 8th grade level or lower. 3.Acronyms may give different ideas than what the material is stating. 4.Allowing for people to take freely is good, but small print can deter someone from reading the information. Bold and bright print is best. 12. A pediatric clinic nurses main responsibilities include: 1. Assessing parenting styles. 2. Assessing readiness to learn for the patient and family. 3. Documentation of family and parental responses to education. 4. Assessing the culture of the family. 5. All of the above. 6. None of the above. ANS: 5 Feedback 1. It is a responsibility along with others. 2. It is a responsibility along with others. 3. It is a responsibility along with others. 4. It is a responsibility along with others. 5. Correct because all are responsibilities of the nurse. 6. One answer is correct. 13. Grant, who is 16, is at the pediatric clinic for his yearly checkup. The nurse requests that his father step out of the patient room because: 1. Grants father is not providing information the nurse needs. 2. Grant appears apprehensive with his father in the room. 3. Grant has a right to confidentiality to discuss his use of alcohol. 4. Privacy is not appropriate for this age range, and the father should remain in the room. ANS: 3 Feedback 1. Confidentiality is appropriate due to Grants age. 2. The question does not give information about the interaction between Grant and his father. 3. Privacy about topics such as substance use is appropriate for this age range. 4. Grant has a right to confidentiality due to his age. 14. A medical chaperone is advisable for a 14-year-old girl when: 1. Having an exam of the breasts. 2. Having an eye exam. 3. Having a hearing screen. 4. Having her height and weight taken. ANS: 1 Feedback 1.A medical chaperone should be present because of the invasiveness of the procedure. 2.A medical chaperone is recommended, but not a necessity. 3.A medical chaperone is recommended, but not a necessity. 4.A medical chaperone is recommended, but not a necessity. 15. A 9-year-old has come to the nurses office at the school complaining of arm pain. The nurse examines the arm and notices fingertip bruises on the forearm, as if it has been squeezed tightly. The nurse talks to the child about how the arm got the bruises. The next action the school nurse should take is: 1. Report this to the classroom teacher, principal, and Child Protective Services since it is a questionable mark on the forearm. 2. Let the child go back to the classroom since this is a normal bruising pattern that children get at this age through play. 3. Let the child go back to the classroom since the child explains that the bruises came from a game of tag. 4. Document the bruising and follow up with the child in two days to make sure it is healing. ANS: 1 Feedback 1. The nurse is a mandatory reporter and should speak with the people listed because bruising like this is abnormal for a child. 2. This is an abnormal bruising pattern for child. 3.Documentation and notification should occur because this is an abnormal bruising pattern for a child. 4.Documentation and notification should occur because this is an abnormal bruising pattern for a child. 16. Ali is a new graduate nurse and has been working on the nursing unit for six months. Ali has noticed that the nurses station attempts to keep patient information confidential. Which of the following actions are not good practices for maintaining confidentiality? 1. Placing the patient chart upside down on the desk when not in use so the name is not revealed. 2. Speaking of patients by room number, not by name. 3. Staying logged onto a computer to answer a call light. 4. Removing patient identifiers on a medication bottle and throwing it into the garbage can. ANS: 3 Feedback 1.This is a good practice for confidentiality. 2.This is a good practice for confidentiality. 3. This allows for anyone to see the computer information about a patient, thus breaking confidentiality. 4. This is a good practice for confidentiality. 17. HIPAA requires health-care providers and employees to be cognizant of: 1. Placement of computer screens to the public. 2. Where discussions about patients occur. 3. How and where change of shift reports occur. 4. All of the above are areas to keep confidential. ANS: 4 Feedback 1.Follows HIPAA confidentiality along with others. 2.Follows HIPAA confidentiality along with others. 3.Follows HIPAA confidentiality along with others. 4.Computer screens, discussions, and change of shift reports should be kept confidential to follow HIPAA guidelines. 18. Jake, a 14-year-old terminal leukemia patient, has told his parents and his health-care providers that he no longer wants to take chemotherapy treatments. The nurse knows that Jake: 1. Can make this decision because he is of legal medical age. 2. Is not of legal age to make a medical decision. This is an ethical decision that must be discussed only with Jakes parents. 3. Must discuss this ethical issue with his parents. 4. Is not of legal age to make a medical decision, thus he has not right to determine his care. ANS: 3 Feedback 1. Jake is not of legal age to make a medical decision, but he is of an age where he is aware of his body and the medical teams actions. 2. Jake should be a part of the discussion because he is at an age where he is aware of his body and medical needs. 3. Jake and his parents should make the decision together. 4. Jakes parents have medical power of attorney, but he is at an age where his wants and needs should be taken into consideration. 19. JoJo, a 10-year-old patient in room 1232 with a right arm and leg amputation due to osteosarcoma, has been refusing help with his daily routine. JoJo is exhibiting: 1. Beneficence. 2. Justice. 3. Veracity. 4. Autonomy. ANS: 4 Feedback 1. This is an act for a nurse to do good, not harm a patient. 2. This is the obligation for caring for the patient. 3. This is the act of telling the patient the truth. 4. This is an act of exhibiting the need to do things by oneself. 20. A home-care pediatric nurse is taking care of an immobile three year old with a home ventilator. The nurse knows she must maintain proper positioning for the child in order to prevent bedsores from developing. This knowledge is known as: 1. Justice. 2. Beneficence. 3. Veracity. 4. Fidelity. ANS: 2 Feedback 1. This is the obligation for caring for the patient. 2. This is an act for a nurse to do good, not harm a patient. 3.This is the act of telling the patient the truth. 4.This is a nurses responsibility for providing the best care possible for the patient. Chapter 3. Family Dynamics and Communicating with Children and Families MULTIPLE CHOICE 1. A nurse is teaching parents how to apply time-out as a disciplinary method for their 4 year old. Parents have understood the teaching if they state which formula correctly guides the use of time-out? a. Use the guideline of 1 minute per each year of the childs age. b. Relate the length of the time-out to the severity of the behavior. c. Never use time-out for a child younger than age 4 years. d. Follow the time-out with a treat. ANS: A In time-out, the child is told to sit on a chair for a predetermined time, usually 1 minute per year of age. Relating time to a behavior is subjective and inappropriate when the child is very young. Time-out can be used with a toddler. Negative behavior should not be reinforced with a positive action. DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance 2. What is the nurses best approach when an 8-year-old boy frequently causes a disruption in the playroom by taking toys from other children? a. Exclude the child from the playroom. b. Explain to the children in the playroom that he is very ill and should be allowed to have the toys. c. Approach the child in his room and ask, Would you like it if the other children took your toys from you? d. Approach the child in his room and state, I am concerned that you are taking the other childrens toys. It upsets them and me. ANS: D The nurse can focus on the behavior most effectively by using I rather than you messages. A you message criticizes the child and uses guilt in an attempt to change behavior. Banning the child from the playroom will not solve the problem. The problem is the childs behavior, not the place where the child exhibits it. Illness is not a reason for a child to be undisciplined. When the child recovers, the parents will have to deal with a child who is undisciplined and unruly. The child should not be made to feel guilty and to have his or her self-esteem attacked. DIF: Cognitive Level: Application REF: p. 34 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 3. Families that deal most effectively with stress have which behavior patterns? a. Focus on family problems. b. Feel weakened by stress. c. Expect that some stress is normal. d. Feel guilty when stress exists. ANS: C Healthy families recognize that some stress is normal in all families, focus on family strengths rather than on the problems, and know that stress is temporary and may be positive. Because some stress is normal in all families, there is no reason to feel guilty. Guilt only immobilizes the family and does not lead to a resolution of the stress. DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 4. Which family will most likely have the greatest difficulty in coping with an ill child? a. A single-parent mother who has the support of her parents and siblings b. Parents who have just moved to the area and are living in an apartment while they look for a house c. The family of a child who has had multiple hospitalizations related to asthma and has adequate relationships with the nursing staff d. A family in which there is a young child and four older married children who live in the area ANS: B Parents who are in a new environment will have increased stress related to their lack of a support system. If only one parent is available but has the support of her extended family, this will assist in her adjustment to the crisis. The family that has had positive experiences in the past with hospitalizations can draw from those experiences and feel confident about the current setting. For the family with one younger child and four older married children who live in the area, the family has an extensive support system, which will assist the parents in adjusting to the crisis. DIF: Cognitive Level: Application REF: p. 27 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 5. Which is the priority nursing intervention for the family of a child who has been admitted to the hospital? a. Begin discharge teaching. b. Identify and mobilize internal and external strengths. c. Identify ways in which the family could have prevented their childs hospitalization. d. Instruct the parents on normal growth and development. ANS: B Family interventions should be directed toward enhancing positive coping strategies and directing the family to appropriate resources. Although discharge teaching is begun as soon as possible, it is ineffective if trust has not been established with the parents or if the level of stress precludes learning. By identifying weaknesses instead of focusing on strengths, the familys anxiety and feelings of powerlessness or guilt may increase. Normal growth and development should be interwoven into teaching; however, teaching cannot take place until the parents have less stress and are open to information. DIF: Cognitive Level: Application REF: p. 27 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 6. A nurse is planning culturally competent care for a child of Hispanic descent. Which characteristic found in a Hispanic family should the nurse include in the plan of care? a. Stoicism b. Close extended family c. Docile children are considered weak d. Very interested in health-promoting lifestyles ANS: B Most Mexican-American families are very close and it is not unusual for children to be surrounded by parents, siblings, grandparents, and godparents. It is important to respect this cultural characteristic and to see it as a strength, not a weakness. Although stoicism may be present in any family, Mexican-American families tend to be more expressive. Considering docile children as weak is a characteristic of American Indians. Although there is a trend for everyone to embrace more health-promoting lifestyles, it is more prominent in Anglo- Americans. DIF: Cognitive Level: Application REF: p. 28 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 7. While reviewing nursing documentation on dietary intake for a 7-year-old child of Asian descent, the nurse notes that he consistently refuses to eat the food on his tray. Which assumption is most likely accurate? a. He is a picky eater. b. He needs less food because he is on bed rest. c. He may have culturally related food preferences. d. He is probably eating between meals and spoiling his appetite. ANS: C When cultural differences are noted, food preferences should always be obtained. A child will often not eat unfamiliar foods. Although the child may be a picky eater, the key point is that he is from a different culture. The foods he is being served may seem strange to him. Nutrition plays an important role in healing. Although the child expends less energy while on bed rest, he has increased needs for good nutrition. Although it should be determined whether the child is eating food the family has brought from home, it is more important to determine his food preferences. DIF: Cognitive Level: Application REF: p. 28 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 8. To resolve family conflict, it is necessary to have open communication, accurate perception of the problem, and a(n): a. intact family structure. b. arbitrator. c. willingness to consider the view of others. d. balance in personality types. ANS: C Without the willingness of the members of a group to consider the views of others, conflict resolution cannot take place. The structure of a family may affect their dynamics, but it is still possible to resolve conflict without an intact family structure if all the ingredients of conflict resolution are present. Conflicts can be resolved without the assistance of an arbitrator. Most families have diverse personality types among their members. This may make conflict resolution more difficult; however, it should not impede it if the ingredients of conflict resolution are present. DIF: Cognitive Level: Knowledge REF: p. 27 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 9. A nurse is planning a parenting class for expectant parents. Which statement is true about the characteristics of a healthy family? a. The parents and children have rigid assignments for all the family tasks. b. Young families assume total responsibility for the parenting tasks, refusing any assistance. c. The family is overwhelmed by the significant changes that occur as a result of childbirth. d. Adults agree on the majority of basic parenting principles. ANS: D A trait of a healthy family is that adults agree on the basic principles of parenting so that minimal discord exists. A significant stressor for families is lack of shared responsibility in the family. Lack of flexibility in parental tasks is likely to create stress and conflict. Admitting to and seeking help with problems, rather than refusing assistance, is a trait of a healthy family. Adjusting to the birth of a child is a significant change for a family. A sense of feeling overwhelmed by this change indicates that the family is not coping effectively. DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 10. A nurse determines that a child consistently displays predictable behavior and is regular in performing daily habits. Which temperament is the child displaying? a. Easy b. Slow-to-warm-up c. Difficult d. Shy ANS: A Children with an easy temperament are even tempered, predictable, and regular in their habits. They react positively to new stimuli. A high activity level and adapting slowly to new stimuli are characteristics of a difficult temperament. The slow-to-warm-up temperament type prefers to be inactive and moody. Shyness is a personality type and not a characteristic of temperament. Being moody is a characteristic of a slow-to-warm up temperament. DIF: Cognitive Level: Analysis REF: p. 33 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 11. The parent of a child who has had numerous hospitalizations asks the nurse for advice because her child has been having behavior problems at home and in school. In discussing effective discipline, which is an essential component? a. All children display some degree of acting out and this behavior is normal. b. The child is manipulative and should have firmer limits set on her behavior. c. Use positive reinforcement and encouragement to promote cooperation and the desired behaviors. d. Underlying reasons for rules should be given and the child should be allowed to decide on which rules should be followed. ANS: C Using positive reinforcement and encouragement to promote cooperation and desired behaviors is one of the three essential components of effective discipline. Behavior problems should not be disregarded as normal. It would be incorrect to assume the child is being manipulative and should have firmer limits set on her behaviors. Providing the underlying reasons for rules and giving the child a choice concerning which rules to follow constitute a component of permissive parenting and are not considered an essential component of effective discipline. DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 12. A nurse assesses that parents discuss rules with their children when the children do not agree with the rules. Which style of parenting is being displayed? a. Authoritarian b. Authoritative c. Permissive d. Disciplinarian ANS: B A parent who discusses the rules with which children do not agree is using an authoritative parenting style. A parent who expects children to follow rules without questioning is using an authoritarian parenting style. A parent who does not consistently enforce rules and allows the child to decide whether he or she wishes to follow rules is using a permissive parenting style. A disciplinarian style would be similar to the authoritarian style. 13. Which information should the nurse include when preparing a 5-year-old child for a cardiac catheterization? a. A detailed explanation of the procedure b. A description of what the child will feel and see during the procedure c. An explanation about the dye that will go directly into his vein d. An assurance to the child that he and the nurse can talk about the procedure when it is over ANS: B For a preschooler, the provision of sensory information about what to expect during the procedure will enhance the childs ability to cope with the events of the procedure and will decrease anxiety. Explaining the procedure in detail is probably more than the 5-year-old child can comprehend and it will produce anxiety. Using the word dye with a preschooler can be frightening for the child. The child needs information before the procedure. DIF: Cognitive Level: Application REF: pp. 44-45 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 14. Who are the experts in planning for the care of a 9-year-old child with a profound sensory impairment who is hospitalized for surgery? a. The childs parents b. The childs teacher c. The case manager d. The primary nurse ANS: A The parents, as primary caregivers, can identify the childs needs to help develop an effective, individualized plan of care. The childs teacher is not as expert as the childs parents for planning her care. The case manager is not as aware as the parents are of the childs individual needs. The primary nurse would use the childs parents as resources in planning the best approach to the childs care. DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 15. Which is an effective technique for communicating with toddlers? a. Have the toddler make up a story from a picture. b. Involve the toddler in dramatic play with dress-up clothing. c. Repeatedly read familiar stories to the child. d. Ask the toddler to draw pictures of his fears. ANS: C Ritualism is a characteristic of the toddler period. By repeating familiar stories and other rituals, the toddler feels a sense of control, which facilitates communication. Most toddlers do not have the vocabulary to make up stories. Dramatic play is associated with older children. Toddlers probably are not capable of drawing or verbally articulating their fears. DIF: Cognitive Level: Application REF: p. 44 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 16. What is the most important consideration for effectively communicating with a child? a. The childs chronological age b. The parentchild interaction c. The childs receptiveness d. The childs developmental level ANS: D The childs developmental level is the basis for selecting the terminology and structure of the message most likely to be understood by the child. The childs age may not correspond to the developmental level; therefore, it is not the most important consideration for communicating with children. Parentchild interaction is useful in planning communication with children, but it is not the primary factor in establishing effective communication. The childs receptiveness is a consideration in evaluating the effectiveness of communication. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 17. Which behavior is most likely to encourage open communication? a. Avoiding eye contact b. Folding arms across the chest c. Standing with head bowed d. Soft stance with arms loose at the side ANS: D A swaying body with arms loose at the sides suggests openness. Avoiding eye contact does not facilitate communication. Folding arms across the chest and standing with head bowed are closed-body postures, which do not facilitate communication. DIF: Cognitive Level: Comprehension REF: pp. 39-40 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 18. Which strategy is most likely to encourage a child to express feelings about the hospital experience? a. Asking close-ended questions b. Asking direct questions c. Sharing personal experiences d. Actively listening ANS: D Active listening encourages conversation. Direct questions and close-ended questions can threaten and block communication. Talking about yourself shifts the focus of the conversation away from the child. DIF: Cognitive Level: Application REF: p. 38 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 19. Which is the most appropriate question to ask to encourage conversation when interviewing an adolescent? a. Are you in school? b. Are you doing well in school? c. How is school going for you? d. How do your parents feel about your grades? ANS: C Open-ended questions encourage communication. Direct questions with yes or no answers do not encourage conversation. Direct questions that can be interpreted as judgmental do not enhance communication. Asking adolescents about their parents feelings may block communication. DIF: Cognitive Level: Application REF: p. 45 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 20. What is the most appropriate response for the nurse to make to the parent of a 3-year-old child found in a bed with the side rails down? a. You must never leave the child in the room alone with the side rails down. b. I am very concerned about your childs safety when you leave the side rails down. The hospital has guidelines stating that side rails need to be up if the child is in the bed. c. It is hospital policy that side rails need to be up if the child is in bed. d. When parents leave side rails down, they might be considered as uncaring. ANS: B To express concern and then choose words that convey a policy is appropriate. Framing the communication in the negative does not facilitate effective communication. Stating a policy to parents conveys the attitude that the hospital has authority over parents in matters concerning their children and may be perceived negatively. No statement should convey blame and judgment to the parent. Chapter 4. Cultural, Spiritual, and Environmental Influences on the Child Multiple Choice 1. Elsa is working with an 11-year-old patient in the outpatient pediatric clinic. As Elsa reviews the chart, she reads that the patient follows the Muslim tradition. When Elsa enters the room, she notes that the child is wearing a hijab on her head. Elsa has never worked with this tradition before. Elsa should: 1. Realize that her verbal and non-verbal communication will impact the care she gives the child. 2. Not ask the parent for input on the care of the child because this would disrespect the family and child. 3. Have another nurse, who has experience with this culture, take care of the patient. 4. Realize that the patient is uncomfortable and seek a fellow nurse to help her. ANS: 1 Feedback 1. Verbal and non-verbal communication differs in each culture, thus this must be taken into consideration when working with the child. 2. The lack of communication with the parent and child is not therapeutic for the child. 3. Another nurse may be beneficial, but since Elsa has already started caring for the child, this may create problems. 4. There is no indication of the patient feeling uncomfortable. 2. A pediatric nursing class has been assigned to use the Giger and Davidhizar Transcultural Assessment Model. The students are assigned to families they do not have a prior relationship with. When performing the assessment, one of the students is given a seat in close proximity to a grandmother on the couch. The student should know that according to this model: 1. Visiting a family is considered a privilege. 2. It is important to identify the family lifestyle. 3. Sitting close to the grandmother can affect the communication. 4. Only the interpersonal relationships of the individuals are emphasized. ANS: 3 Feedback 1. Does not address the economic standing of the family 2. Does not identify a lifestyle 3. Space is a component of the model. 4. Views the familys interactions with society 3. A staff educational day has been planned for the pediatric unit of a major hospital. The goal is to make the staff culturally competent. This is important because: 1. This competency meets JCAHO requirements. 2. This competency meets cultural care requirements for the hospital system. 3. This allows nurses to tailor their care to the patient and provide holistic care. 4. This education is needed to reach Magnet status. ANS: 3 Feedback 1. Not the purpose of the goal 2. Can be a purpose of the hospital, but does not take precedence over the patient. 3. Important to view the patient holistically in order to provide quality care 4.Not the purpose of the goal 4. Hussains parents have a language barrier with the nursing staff on the pediatric floor. When working with communication barriers, it is important to: 1. Use pictures when an interpreter is not available. 2. Use hand gestures to attempt to communicate. 3. Ask the interpreter to speak to the family over the phone. 4. Require the family to provide a family member to interpret. ANS: 1 Feedback 1.This is appropriate if there are pictures for the conversation. 2.Each culture is sensitive to body language. Avoid using gestures because this may offend the family. 3. Speaking over the phone can cause communication breakdown, which will not be effective for the conversation. 4. It is a responsibility of the hospital to provide an interpreter for the patient. 5. Social skills between different cultures are important for a pediatric nurse to understand. All of the following are part of social skills except: 1. Personal space. 2. Eye contact. 3. Diet. 4. Exercise. ANS: 4 Feedback 1. Influences social skills of cultures 2. Influences social skills of cultures 3. Influences social skills of cultures 4. Not an influence of social skills of cultures 6. The community pediatric nurse is conducting a home visit with a new family. The nurse knows when she is in the home, it will be important to get a thorough assessment. The assessment should consist of: 1. The number of family members living in the home. 2. The employment of the adults in the home. 3. How personal space is perceived. 4. All of the above should be considered in the assessment. ANS: 4 Feedback 1.An important component, along with other choices 2.An important component, along with other choices 3.An important component, along with other choices 4.Family members, employment, and personal space should all be assessed by the nurse. 7. Culturally competent care includes: 1. 1. Treating others exactly how you would like to be treated. 2. 2. Seeing individuals as unique. 3. 3. Treating individuals within the same cultural group the same. 4. 4. Providing care without concern of your own values. ANS: 2 Feedback 1.This is important to understand the cultural norms and values 2.Cultural competence includes treating individuals as unique beings. 3.Not all cultural groups follow the same norms and values. 4.Realization of personal values enables the nurse to be culturally competent. 8. A nurse is caring for a 12-year-old patient who has recently been hospitalized. Which statement by the patient proves that the nurse did not perform a complete cultural assessment? 1. Im glad that my prayer times work around my care. 2. I feel better when my mom stays with me. 3. Im not allowed to eat pork, and it is on my lunch tray. 4. My mom does not like it when my room is messy. ANS: 3 Feedback 1.The nurse has planned care to allow for prayer time for the patient. 2.The nurse understands the importance of family. 3. The nurse should have assessed dietary restrictions for the patient and ensured a proper diet is brought to the patient. 4. Family values play a role in the cultural practice of the family. 9. Pediatric visitations should: 1. 1. Be 24 hours a day for parents and grandparents. 2. 2. Be semi-structured for other visitors. 3. 3. Provide time for socialization and playing. 4. 4. All of the above. ANS: 4 Feedback 1.Family-centered care is important to the healing process for the child. 2.Visits should be structured in order to allow the child time to rest. 3. Play helps decrease stress for the child. 4. All of the above statements should be included in visitations. 10. A nurse promotes family-centered care when: 1. 1. Caregivers can room in and provide care to their child. 2. 2. The nurse provides the care as the physician orders. 3. 3. Care is provided after the family steps out of the room. 4. 4. Visitation guidelines are strictly followed. ANS: 1 Feedback 1. Including the family in providing care is being family centered. 2. The family needs to be involved in the care in order for it to be family centered. 3. Care should be provided continuously and hold the needs of the family and patient as a high priority. 4. Visitation guidelines are set by the family, not the staff. 11. When utilizing an interpreter, which item does not need to be documented? 1. 1. Name of the individual interpreting 2. 2. Primary language of the patient and caregiver 3. 3. Pictures used to communicate an idea 4. 4. Understanding of the patient and the care provider ANS: 3 Feedback 1. The name must be provided to verify who is giving the information. 2. The primary language documentation will provide future workers with information to help the patient. 3. If an interpreter is being used, pictures may only supplement the discussion. The interpreter should be communicating the health-care providers explanations word-for-word. 4. Clarity of the information provided through the interpreter should be documented to identify if the family is understanding the information provided. 12. A nursing student understands pediatric cultural and dietary needs when she tells the parent of her patient: 1. 1. You can bring in food from home. 2. 2. The hospital food should be adequate. 3. 3. I dont know how the food is prepared. 4. 4. Food from home will only make your child miss home. ANS: 1 Feedback 1. Food from home will comfort the child and help him/her understand the types of food that are seen as healthy choices in a time of illness. 2. Hospital food may not be prepared in the proper manner for consumption by some cultures. 3. Learning how the food is prepared will enable the staff to provide for the needs of the child. 4. Children will eat food that is familiar to them and is in compliance with their cultural and spiritual needs. 13. Staff education should include: 1. 1. Education on cultures common to their practice. 2. 2. Annual updates and reviews. 3. 3. Self-reflection on the care providers own values and beliefs. 4. 4. All of the above. ANS: 4 Feedback 1. Education should provide information about cultures the staff is not exposed to frequently. 2. Updates and reviews will allow staff to identify the needs of the patients on a continuous basis. 3. Self-reflection will identify biases and how not to let them interfere with the care provided to the patient. 4. All of the above answers should be included in staff education. 14. Spiritual assessments should be performed: 1. 1. During every contact with health-care providers. 2. 2. During hospitalizations. 3. 3. Annually. 4. 4. As needed. ANS: 1 Feedback 1. Spiritual assessments should be conducted during every contact with health-care providers. This would include well-child visits. 2. May need to know this information for immunizations and at well-child checkups. 3. Should be done at each visit in case the situation has changed for the patient. 4. Needs to be performed at every visit to identify changes in the spiritual needs. 15. Effective communication can be confirmed when: 1. 1. The patient or caregiver asks questions. 2. 2. When the patient and caregiver do not verbalize questions. 3. 3. The receiver of the messages understands the information as the provider intended the message to be received. 4. 4. The receiver of the message speaks the same language as the person giving the message. ANS: 3 Feedback 1.Questions are asked to verify information and gather more information. 2.The patient and caregiver may need time to think about information before asking questions. 3. Effective communication entails understanding the message that the sender intended for the receiver. 4. The language does not determine the understanding of the patient or caregiver. 16. When performing an initial assessment, the FICA Spiritual Assessment tool will: 1. 1. Help the care provider to include spiritual needs in the care plan. 2. 2. Will complete the questionnaire in the chart. 3. 3. Be answered by the parent or care provider. 4. 4. Only be answered by the patient. ANS: 1 Feedback 1. The FICA tool assesses faith, importance, community, and addresses care needs within the care plan. 2. Information will be gathered, but should not be the basis of the history or the care. 3. The child should be allowed to have input. 4. The family will have an influence on the spiritual care of the child. 17. An example of a nurse-patient relationship would be: 1. 1. Attending a birthday party outside of the hospital. 2. 2. Providing special toys for favorite patients. 3. 3. Reporting suspected child abuse. 4. 4. Keeping a secret about suspected child abuse to keep confidentiality with the patient. ANS: 3 Feedback 1.The birthday party is beyond the professional boundaries of a nurse. 2.Demonstrating favoritism is not a professional action a nurse should display. 3.Nurses must report actual or suspected child abuse. 4.A nurse is a mandatory reporter and must report any suspicions of child abuse. 18. The medical clinics staff ensures quality multidisciplinary care by: 1. 1. Following hospital policies. 2. 2. Documenting and sharing all information. 3. 3. Not questioning other disciplines. 4. 4. Utilizing the correct form when obtaining data. ANS: 2 Feedback 1.Hospital policies may be unit and discipline specific. 2.Multidisciplinary relationships include sharing information and having respect for differences in opinion. 3. Questions should be asked in order to strive for the best care possible for a patient. 4. Forms are important, but do not always reflect needs of the entire staff. 19. Which finding most likely demonstrates lack of full disclosure? 1. 1. Health questionnaire completed in the waiting room 2. 2. Inability to explain how long symptoms have occurred 3. 3. Poor eye contact during exam 4. 4. Providing family history ANS: 2 Feedback 1. Others may be able to see the paperwork being filled out in a waiting room. 2. Potential embarrassment and disgrace to have a disease may prevent the patient or caregiver from discussing the length of symptoms. 3. Based on culture, eye contact may not be allowed. 4. Family history does not provide full disclosure of the needs of the patient. 20. A parent with a low-income job can get more groceries with less money when: 1. 1. Purchasing processed food. 2. 2. Purchasing fresh fruits and vegetables. 3. 3. Purchasing meat products. 4. 4. Purchasing snack foods. ANS: 1 Feedback 1. Processed foods are less expensive and have lower nutritional value than fresh foods. 2. Fresh fruits and vegetables tend to be higher priced in certain parts of the country because of the cost of shipping and the season. 3. Meat is expensive because of the cost of processing and shipping. 4.Snack foods come in small packages and do not provide nutritional content. Snack foods are more expensive for the quantity. 21. The nurse tells the caregivers of a 5-year-old patient that the patient will be discharged at lunch time. At 12:00 noon, the family is not present, but does come in at 2:00 p.m. The caregivers are wondering why the nurse thinks that they are late. This could be attributed to: 1. 1. Lack of discharge paper processing. 2. 2. Cultural differences in lunch time. 3. 3. The caregivers believing that the child is being watched adequately. 4. 4. The nurse being busy and losing track of time. ANS: 2 Feedback 1. The discharge paper processing cannot be completed without the caregivers being present. 2. Appointments should be made by clock time, not daily event times. 3.The caregivers may have a difference of opinion on time. 4.The later discharge occurred because the caregiver did not arrive at the set time. 22. The female caregiver of a patient wears a scarf that covers her head and face when males enter the room. The nurse noted that male nurses were entering the room without notice to the caregiver. The nurses best action would be to: 1. 1. No intervention is needed by the nurse. 2. 2. Place a sign on the door stating that all males must first knock and ask permission prior to entering the room. 3. 3. Only allow female caregivers. 4. 4. Only allow male caregivers. ANS: 2 Feedback 1.A plan should be made to help the female care provider feel at ease. 2.The family is considered the patient in pediatrics. Nurses should advocate and provide interventions that will maintain the cultural beliefs of the family unit. 3.Solely female caregivers may not be arranged because of staffing. 4.Solely male caregivers may not be arranged because of staffing. 23. Due to genetics, African American patients are at higher risk for: 1. 1. Liver cancer. 2. 2. Injury. 3. 3. Infectious diseases. 4. 4. Diabetes. ANS: 4 Feedback 1. Liver cancer is seen more in Caucasian males. 2. Injury is the highest risk factor for all ages of children, no matter the race. 3. Infectious diseases do not have a higher presence in one race over another. 4. African Americans are at a higher risk for diabetes due to genetics. 24. European Americans may wear a horn charm to ward off evil spirits. They believe that diseases may be caused from a curse called: 1. 1. The evil spirit of the ancestors. 2. 2. The disease. 3. 3. The evil spell. 4. 4. The maloic. ANS: 4 Feedback 1. The curse of the evil spirits may be a reason to wear the horn. 2. The disease is not seen as an evil spirit. 3. The evil spell can be the outcome of the disease process. 4. The maloic is the curse that is thought to cause disease. 25. Asian Americans may use this to cure diseases. 1. 1. Balance of hot and cold fluids 2. 2. Increased vegetable intake 3. 3. Increase in exercise to sweat out impurities 4. 4. Well-balanced diet ANS: 1 Feedback 1.Asians believe in the balance of hot and cold in the body. 2.Vegetables are common in the Asian American diet. 3.Exercise is not seen as a way to rid impurities of the body in order to help with an illness. 4.A well-balanced diet is important, but is not noted to be the cure of for diseases. 26. Spirituality can be defined as: 1. 1. Defining God. 2. 2. Feeling a greater being has control over world events. 3. 3. The concept of where and how the human race began. 4. 4. All of the above. ANS: 4 Feedback 1.God can come in different forms for all patients and caregivers. 2.A greater being gives a sense of control. 3.Ideas of how the human race began helps with coping for patients. 4.Spirituality is defining God, feeling a greater being has control over world events, and the concept of where and how the human race began. 27. This religious affiliation may not accept blood products, so frequent blood draws and procedures that may involve blood loss should be limited. 1. 1. Atheism 2. 2. Buddhism 3. 3. Jehovahs Witness 4. 4. Judaism ANS: 3 Feedback 1. Atheism does not have a belief system that affects any medical procedure. 2. Buddhism seeks a balance and will accept blood products. 3.Jehovahs Witnesses may not accept blood transfusions. 4.Judaism allows for blood procedures. 28. These two religious affiliations do not eat pork products. 1. 1. Muslim and Mormonism 2. 2. New Age and Atheism 3. 3. Judaism and Muslim 4. 4. Judaism and Buddhism ANS: 3 Chapter 5. End-of-Life Care Multiple Choice 1. The pediatric nurse is having a conversation with parents who have children that have recently passed away. The nurse knows the parents understand the difference between bereavement and grief when the participants state: 1. I am trying to prepare for my daughters death, but I just am not ready to do so. 2. Bereavement has caused me to experience sorrow for the loss of my daughter. 3. I cant believe my daughter is gone. 4. If I make a deal that God takes me, then my daughter could come back to my family. ANS: 2 Feedback 1. The parents are stating anticipatory grief. 2. The parents are stating bereavement. 3. The parents are in the denial phase of grieving. 4. The parents are bargaining. 2. The medical chart states that the parents are requesting withdrawal of care for a child with terminal leukemia. The nurse understands this request to mean: 1. To keep support measures which sustain life for the child. 2. To keep providing comfort care for the child. 3. To stop life-saving measures and allow the child to die naturally. 4. To stop providing comfort measures for the child. ANS: 3 Feedback 1. Support measures are not wanted by the parents. 2. Comfort care is important, but this addresses the life-sustaining measures. 3. Withdrawal of care relates to stopping heroic measures to sustain life. 4.Comfort is essential in the last days of life for the family and the patient. 3. Ashley is a 5-year-old girl who is severely mentally handicapped and has been bedridden for the last 3 years after a near-drowning accident. Ashley has developed pneumonia and sustaining her life would require ventilator support. The staff nurse is to obtain information about legal guardianship because her parents have abandoned her at the hospital. The nurse knows that: 1. Legal guardianship is needed for a person to have medical information released to him/her. 2. The legal guardian must be present to care for the child. 3. Legal guardianship can only be obtained by her parents. 4. The legal guardian must take physical responsibility for the child. ANS: 1 Feedback 1. The medical information and consent needs to be given by someone with the best interests of the child in mind who can legally make decisions. Only information can be released to this person. 2. The legal guardian does not need to be physically present, but must be reachable to discuss the plan of care. 3. Legal guardians can be anyone with the best interests of the child in mind. 4. The legal guardian may be the state, and foster parents would have the physical responsibility of caring for the child. 4. Identify a developmentally-appropriate activity that can be used to speak to a 6 year old about the terminal illness of his sibling. 1. Playing checkers and speaking about the illness. 2. Playing with action figures and discussing how death occurs. 3. Playing with crayons and drawing pictures of how a child views his sibling at this time. 4. All of the above are correct. ANS: 4 Feedback 1. Having a diversional activity allows the child to express themselves without having to look directly at the adult. 2. Action figures can help act out how death occurs. 3.Expression through art is a technique that children are able to comprehend and is not threatening to them. 4. Diversion, acting, and art can help children express and discuss the death process. 5. Palliative care should be considered for a terminally-ill child: 1. Within 1 year of death. 2. Within 2 months of death. 3. When a terminal illness is present. 4. At no time. It is not appropriate for children. ANS: 3 Feedback 1. Planning can occur, but should be started when a terminal diagnosis is present to provide the plan of care for the child. 2. Planning can occur, but should be started when a terminal diagnosis is present to provide the plan of care for the child. 3. The knowledge of the terminal illness and letting the family and patient be involved in the decision-making processes facilitates palliative care so that the patient is as comfortable as possible. 4. Palliative care is appropriate for children with a terminal illness. 6. Palliative care allows the child to: 1. Have a graceful, natural death. 2. Attempt to use every type of medical process possible to sustain life. 3. Abruptly end life. 4. Comfort the family before death. ANS: 1 Feedback 1. Palliative care focuses on the natural death process in the most comforting way possible. 2. Medical processes to sustain life are not considered important in palliative care. 3. Palliative care works with patients once a terminal illness is diagnosed in order to have a plan of care. 4. Palliative care helps comfort the family and the patient. 7. One of the best indicators of pain in a child is: 1. A change in the baseline vital signs. 2. Parents input. 3. Restlessness. 4. All of the above can be seen in children with pain. ANS: 4 Feedback 1.A sign of pain in a child 2.Parents tend to recognize changes in their children before others. 3.Children in pain can be restless. 4.Vital signs, parents input, and restlessness can all be signs of pain in a child. 8. A nurse is discussing pain management for a child near death. The child does not have an IV, and the parents do not want their child to suffer more pain. The nurse knows medication at this point in the childs life should: 1. Be given by the quickest route for maximum relief. 2. Be delivered in the most invasive manner. 3. Be given through IV. 4. Be discussed with the doctor because a child near death cannot feel pain. ANS: 2 Feedback 1. The quickest route may be very painful for the child. 2. The most invasive manner can cause less pain. 3. The IV is not established. 4. Children near death can feel pain. 9. Identify an activity that is an alternative pain management technique. 1. Blowing bubbles 2. Holding and rocking the child 3. Playing with puzzles 4. All of the above can be used as alternative pain management techniques. ANS: 4 Feedback 1.A form of alternative pain management, along with other options 2.A form of alternative pain management, along with other options 3.A form of alternative pain management, along with other options 4.Bubbles, rocking, and puzzles are all alternative pain management techniques for children. 10. A staff nurse knows a childs view of death is influenced by and . 1. Developmental age, mental status 2. Cognition, mental status 3. Developmental age, cognition 4. Physical status, age ANS: 3 Feedback 1. Developmental age does define how the child will understand the process, but mental status does not. 2. Cognition does define how the child will understand the process, but mental status does not. 3. Developmental age demonstrates what a child is able to understand, along with cognition. 4. Physical status does not give an idea of the cognitive level of the child. Age does not determine cognition. 11. A 3 year old is diagnosed with terminal grade four neuroblastoma, which has side effects of balance and hearing issues. The childs mother asks the nurse about an appropriate, safe activity for the child. The nurse tells the mother that the most appropriate type of play is: 1. 1. No play is good. The child should remain in bed. 2. 2. Play groups with children in the neighborhood. 3. 3. Age appropriate gymnastic classes. 4. 4. Quiet play with minimal stimuli, such as puzzles or books. ANS: 4 Feedback 1.Playing is a normal part of learning and should be considered. 2.Play groups may cause too much stimulation and cause negative reactions from the child. 3.A gymnastics class is too much stimulation and the child may have issues with balance. 4.Quiet play with minimal stimuli is the most appropriate for a child with balance and hearing issues. 12. The nurse is aware that there are two causes of pediatric death. They are: 1. 1. Psychological and physiologic. 2. 2. Trauma and physiologic. 3. 3. Trauma and psychological. 4. 4. Physiologic and external. ANS: 2 Feedback 1.Physiological issues are not a leading cause for death in pediatric patients. 2.A terminal pediatric diagnosis is categorized into two causes: trauma and physiologic. 3.Physiological issues are not a leading cause for pediatric death. 4.External factors are not a reason for death in pediatric patients. 13. A nurse in a maternity unit is providing emotional support to a patient and her husband who are preparing to be discharged from the hospital after the birth of a stillborn, full-term infant. Which statement, if made by the patient, indicates a component of the normal grieving process? 1. 1. We would really like to attend a support group. 2. 2. We are ok. We are going to work on having another baby now. 3. 3. We never want to have a baby again or talk about our loss. 4. 4. We are filling out the paperwork to adopt a baby. ANS: 1 Feedback 1. This is the best answer to demonstrate the normal grieving process, but other answers can be true if people are struggling with the grieving process. 2. The parents are not taking the time to grieve for the child they lost. 3.The parents are making choices at a highly emotional time. The parents should wait to make this decision. 4.The parents are making life decisions too early after the death of their child. 14. A nursing instructor asks a nursing student what the leading causes of death for pediatric-age patients are. Which of the following statements demonstrates that the student is aware of the leading causes of death for pediatric patients? 1. 1. Disease and terminal cancer are the leading causes of death for pediatrics. 2. 2. Abuse and SIDS are the leading causes of death for pediatrics. 3. 3. Accidents or unintentional injuries are the leading causes of death for pediatrics. 4. 4. Accidents and congenital defects are the leading causes of death for pediatrics. ANS: 3 Feedback 1. Disease and terminal illness are not the leading causes of death in pediatric patients. 2. Abuse and SIDS are not the leading causes of death for pediatric patients. 3. Accidents or unintentional injuries are the leading causes of death for pediatric patients. 4. Congenital defects are not a leading cause of death for pediatric patients. 15. Which, if any, of the following circumstances might incline a nurse to become disengaged or enmeshed rather than therapeutically engaged with a patient/family? 1. 1. 5-year-old child dying of cancer 2. 2. 6-month-old infant in a vegetative state due to an inflicted head injury 3. 3. Dying 10-day-old neonate with anencephaly whose parents do not visit 4. 4. All of the above ANS: 4 Feedback 1. The situation is emotionally charged in a manner that might incline a nurse to distance herself from or become enmeshed with the child and/or the family. 2. The situation is emotionally charged in a manner that might incline a nurse to distance herself from or become enmeshed with the child and/or the family. 3. The situation is emotionally charged in a manner that might incline a nurse to distance herself from or become enmeshed with the child and/or the family. 4. Each of the situations is emotionally charged in a manner that might incline a nurse to distance herself from or become enmeshed with the child and/or the family. 16. The nurse is aware that the purpose of pediatric palliative care is: 1. 1. To speed up the process of death and decrease suffering. 2. 2. To promote patient comfort and family involvement. 3. 3. To increase patient comfort and decrease environmental stimuli. 4. 4. To prevent disease and promote overall health. ANS: 2 Feedback 1.The goal of palliative care is to provide a positive death process. 2.Palliative care is provided at the end of life to promote patient comfort and family involvement. 3.The goal is to have family involvement and promote comfort. 4.Palliative care is provided at the end of life to promote patient comfort and family involvement. 17. The nurse is creating a care plan for a terminal 6-year-old child in the hospital for palliative care. Which of the following should be the goal of the care plan? 1. 1. Pain assessment 2. 2. Developmental needs 3. 3. School needs 4. 4. Discharge planning ANS: 4 Feedback 1. Pain assessment and interventions are essential in end of life care, but not the goal. 2. The childs developmental needs are for assessment purposes. 3.Palliative care does not focus on school needs because the end of life should be the focus. 4.Discharge planning is the goal of a palliative care so the child can be in a comfortable home environment with the family. 18. Which, if any, of the following is not an example of family-centered care within palliative care? 1. 1. The childs parents are not invited to participate in medical rounds. 2. 2. Educating the family on the childs pain assessment and pain care to allow them to assist in keeping the child comfortable. 3. 3. Asking the family to help with daily patient care, such as bathing and positioning when appropriate. 4. 4. Choices 2 and 3 ANS: 1 Feedback 1.A childs family should participate in palliative care planning. 2.Family education is an important part of family-centered care. 3.Family involvement in daily care is an example of family-centered care. 4.Parents/guardians should be encouraged, but not required, to participate in medical rounds, nursing shift changes, patient care, and pain assessment at all times during palliative care. 19. Which of the following pain interventions is appropriate for a pediatric patient receiving palliative care? 1. 1. Assess the patients pain using a developmentally appropriate pain scale. 2. 2. Ask the patients family to participate and provide input regarding the patients pain level assessment. 3. 3. Use a combination of prescribed medications, distraction, and positioning to provide comfort and decrease pain. 4. 4. All of the above ANS: 3 Feedback 1. Assessing the pain is not an intervention. 2. The family may not have knowledge on the proper pain scale to be used with the patient. 3. When caring for a patient in palliative care, it is important to use the correct pain scale, involve the patient and family in pain control, and use a combination of methods to increase comfort and decrease pain. 4. When caring for a patient in palliative care, it is important to use the correct pain scale, involve the patient and family in pain control, and use a combination of methods to increase comfort and decrease pain. 20. The nurse is preparing to assess a 4-week-old infant who is suffering from shaken baby syndrome. The most appropriate pain scale is: 1. 1. CHOPS. 2. 2. The numerical scale. 3. 3. VAS. 4. 4. NIPS. ANS: 4 Feedback 1.CHOPS is not used for a neonate assessment. 2.A numerical scale is not able to identify pain in a neonate. 3.VAS is not used to assess pain in a neonate. 4.NIPS, or Neonatal and Infant Pain Scale, is the most appropriate for a 4- week-old infant. 21. When a child is at the end-stage of life, the nursing priority should be: 1. 1. Restoration of health. 2. 2. Health education. 3. 3. Patient comfort. 4. 4. Developmental assessment. ANS: 3 Feedback 1. Comfort care is needed for the child. 2. Health education and developmental assessment are both important, but not a priority. Restoration of health is generally not possible. 3. The nursing priorities during end-of-life care for pediatric patients would focus on patient comfort. Health education and developmental assessment are both important, but not a priority. Restoration of health is generally not possible. 4. Health education and developmental assessment are both important, but not a priority. Restoration of health is generally not possible. 22. The nurse is working in a post-partum unit and is assigned to care for a woman who experienced fetal demise at 40 weeks. The nurse is not comfortable caring for this type of patient, so the best course action for the nurse to take is to: 1. 1. Take the patient and provide the care needed. No one is good at providing care to patients who experience fetal demise. 2. 2. Talk to the charge nurse and see if there is a nurse with more experience in caring for patients who experience a fetal demise. 3. 3. Take the patient. All nurses need to learn to take care of patients who experience a death. 4. 4. Talk to the charge nurse and refuse to take the patient. It is not fair to take a patient the nurse is not comfortable with caring for. ANS: 2 Feedback 1.It is the responsibility of the nurse to not care for the patient. 2.The best response for the nurse to have is to see if there is a better option; if a nurse is uncomfortable with providing end-of-life care and there is a better option, it is the responsibility of the nurse to not care for the patient. 3.It is the responsibility of the nurse to not care for the patient. 4.The best response for the nurse to have is to see if there is a better option. 23. Organ transplant is overseen by: 1. 1. Physicians. 2. 2. A federal-government-funded agency. 3. 3. No one. There is no oversight of organ transplantation. 4. 4. All of the above. ANS: 2 Feedback 1. Organ transplant is overseen by a federal agency to ensure that there is fairness and equity in the distribution of available organs. 2. Organ transplant is overseen by a federal agency to ensure that there is fairness and equity in the distribution of available organs. 3. Organ transplant is overseen by a federal agency to ensure that there is fairness and equity in the distribution of available organs. 4. Organ transplant is overseen by a federal agency to ensure that there is fairness and equity in the distribution of available organs. 24. What federal laws and regulations must be followed during palliative care? 1. 1. HIPAA 2. 2. The Joint Commission 3. 3. OSHA 4. 4. All of the above ANS: 4 Feedback 1.HIPAA should be provided for all patients, no matter their status. 2.The Joint Commission is a certification a hospital may want to receive, not a regulation by law. 3.OSHA is for occupational health standards, not palliative care needs. 4.Palliative care is no different than all other types of health-care delivery and all laws and regulations must be followed. 25. Which, if any, of the following is the correct type of patient to be assigned to palliative care? 1. 1. A 6-year-old boy with an untreatable stage four brain tumor 2. 2. A 2-month-old child with spina bifida 3. 3. A 12-year-old child with a new diagnosis of leukemia 4. 4. All of the above ANS: 1 Feedback 1.A palliative care patient is generally defined as a patient who is within 6 months of death. An untreatable stage four brain tumor will generally cause death within weeks or months. 2. Spina bifida is not a terminal disease. 3. Newly diagnosed leukemia is not a terminal disease. 4.A palliative care patient is generally defined as a patient who is within 6 months of death. An untreatable stage four brain tumor will generally cause death within weeks or months. Spina bifida and newly diagnosed leukemia are not terminal diseases. 26. You are caring for a child recently admitted to the palliative care unit with end-stage heart disease. Which statement by the parents demonstrates that you need to provide education regarding palliative care? 1. 1. We want to have our family here with us, are they able to visit outside of visiting hours? 2. 2. We want to make sure we are always with our child. Can we sleep in the room? 3. 3. We are trying to plan ahead. When do you think our child will be better and able to be discharged? 4. 4. All of the above ANS: 3 Feedback 1. Parents stating that they want their family available and to be with the child at all times are signs of understanding that the child is going to die. 2. Parents stating that they want their family available and to be with the child at all times are signs of understanding that the child is going to die. 3. Palliative care is end-of-life care, and parents may need additional education to help them to come to terms with their child being in palliative care. Gentle education may be needed on an ongoing basis. Parents stating that they want their family available and to be with the child at all times are signs of understanding that the child is going to die. 4. Palliative care is end-of-life care and parents may need additional education to help them to come to terms with their child being in palliative care. 27. When parents are approached about their child becoming an organ donor, it is important for whom to approach the parents? 1. 1. Anyone can approach the parents and ask for them to donate their childs organs. 2. 2. Only physicians can approach the parents and ask for them to donate their childs organs. 3. 3. No one should approach the parents. If they what to donate their childs organs, they will ask the staff. 4. 4. Only staff trained in approaching should approach the parents and ask for them to donate their childs organs. ANS: 4 Feedback 1. Organ donation is a very hard subject to approach the parents of a dying child with, and only staff trained in approaching should approach a family. 2. Organ donation is a very hard subject to approach the parents of a dying child with, and only staff trained in approaching should approach a family. 3. Organ donation is a very hard subject to approach the parents of a dying child with, and only staff trained in approaching should approach a family. 4. Organ donation is a very hard subject to approach the parents of a dying child with, and only staff trained in approaching should approach a family. 28. Which of the following is a priority in caring for a patient whose parents have consented to donating the childs organs? 1. 1. Prepping the patient and family for the surgical procedures to procure the organs 2. 2. Allowing the family as much time as they need to say goodbye to the patient 3. 3. Supporting the family in choosing a funeral home for their child 4. 4. Providing education to the parents about organ donation ANS: 1 Feedback 1. The priority in organ donation patients is to prep them for surgery and organ procurement. The sooner the organs are procured, the more viable the organs. All of the other choices important, but not the top priority. 2. The sooner the organs are procured, the more viable the organs. 3.The funeral home choice should only be made by the family. 4.The parents should have been educated about the donation process prior to the consent being signed. 29. When administering pain medication to a palliative care patient, what needs to be included? 1. 1. Ensure that the correct pain scale is being used. 2. 2. The six rights of medication administration 3. 3. Explanation of medication to the patient and family 4. 4. All of the above ANS: 4 Feedback 1.A correct pain scale will identify the physiological signs of the child. 2.The six rights should be followed with all patients. 3. Explanations should occur for all medications. 4. All of the choices are necessary for correct pain medication administration practice when caring for any patient, including palliative care patients. 30. The nurse responds to a pediatric code in the emergency room. Upon arrival, the nurse finds the parents outside of the room, and they ask if they can go in. The best response the nurse can give is: 1. 1. Family is not allowed in the room during this type of situation. It is best for you to go to the waiting room. 2. 2. You want to remember your child in happier times, not like this. Please wait here. 3. 3. Yes, you may go on in, but stay out of everyones way so that you do not make it worse. 4. 4. Of course. I will go with you. Please do not touch anything until we know what is going on. ANS: 4 Feedback 1. The family should be escorted to a family room so that the child receives all of the care needed. 2. This may increase anxiety for the parents and should be avoided. 3.During a pediatric code situation, it is very important to provide for the safety of the patients family 4.During a pediatric code situation, it is very important to provide for the safety of the patients family. Always ensure that a staff member is assigned to be with the family during the entire code. Chapter 6. Growth and Development MULTIPLE CHOICE 1. When the nurse notes that an infant can lift her head before she can sit, the nurse is assessing: a. Specific to general development b. Proximodistal development c. Cephalocaudal development d. General to specific development ANS: C Cephalocaudal development proceeds from head to toe. DIF: Cognitive Level: Comprehension REF: dm: 348 OBJ: Objective: 2 TOP: Topic: Directional Patterns of Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 2. A unique organization of characteristics that determines an individuals pattern of behavior is known as: a. Environment b. Heredity c. Personality d. Experience ANS: C One definition of personality states that it is a unique organization of characteristics that determines the individuals typical or recurrent pattern of behavior. DIF: Cognitive Level: Knowledge REF: dm: 355 OBJ: Objective: 5 TOP: Topic: Personality Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Maintenance and Promotion 3. An infants birthweight is 7 pounds, 8 ounces. The nurse can project the weight at 6 months to be: a. 12 pounds b. 15 pounds c. 18 pounds d. 22 pounds ANS: B An infant usually doubles his or her birth weight by 5 to 6 months. DIF: Cognitive Level: Application REF: dm: 349 OBJ: Objective: 4 TOP: Topic: Growth KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse assessing patterns of growth in a child would investigate further if: a. Previous weight was in the 75th percentile, and present weight is in the 25th percentile. b. Height is in the 90th percentile, and weight is in the 75th percentile. c. Last weight was in the 5th percentile, and present weight is in the 10th percentile. d. Weight is in the 50th percentile, and siblings weight at the same age was in the 75th percentile. ANS: A The child showing a difference of two or more percentile levels from an established growth pattern should undergo further evaluation. DIF: Cognitive Level: Analysis REF: dm: 351 OBJ: Objective: 3 TOP: Topic: Growth KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A mother reports that she and her husband have had one child together, but both have children from previous marriages living in their home. The nurse will base the care planning on the fact this family type is a: a. Nuclear family b. Blended family c. Alternate family d. Extended family ANS: B A blended family involves the remarriage of persons with children. DIF: Cognitive Level: Comprehension REF: dm: 354, Table 15-1 OBJ: Objective: 9 TOP: Topic: The Family KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The mother of a 7-month-old reports that the first lower central incisor has erupted. She asks the nurse, How many teeth will he have by his first birthday? The nurse would explain that by 1 year of age, the infant usually has: a. Two teeth b. Four teeth c. Six teeth d. Eight teeth ANS: C The 1-year-old infant usually has about six teeth, four above and two below. DIF: Cognitive Level: Comprehension REF: dm: 375 OBJ: Objective: 8 TOP: Topic: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 7. At a well-baby visit, parents of a 6-month-old ask when to take the infant for the first dental visit. The nurses best response would be: a. If the teeth are brushed regularly, the child should see a dentist by 3 years of age. b. The first dental visit should be arranged after the first tooth erupts. c. The child should have a dental examination when all deciduous teeth have erupted. d. A dental visit by 1 year of age is recommended by the American Academy of Pediatric Dentistry. ANS: D The Academy of Pediatric Dentistry recommends that the first dental visit occur by 1 year of age. DIF: Cognitive Level: Application REF: dm: 375 OBJ: Objective: 8 TOP: Topic: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Maintenance and Promotion: Prevention and Early Detection of Disease 8. The nurse planning anticipatory guidance for the caregiver of a preschool-age child would explain that permanent teeth begin erupting about the age of: a. 4 years b. 6 years c. 8 years d. 10 years ANS: B Permanent teeth do not erupt through the gums until the sixth year. DIF: Cognitive Level: Comprehension REF: dm: 375 OBJ: Objective: 8 TOP: Topic: Dentition KEY: Nursing Process Step: Planning MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 9. A mother asks the nurse how much food should be offered to her 2-year-old. The nurse responds that a good rule of thumb for serving size would be: a. 2 tablespoons b. 3 tablespoons c. 4 tablespoons d. 5 tablespoons ANS: A The rule of thumb for serving sizes is to offer 1 tablespoon per year of age. DIF: Cognitive Level: Application REF: dm: 374 OBJ: Objective: 7 TOP: Topic: Rule of Thumb for Serving Sizes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 10. An assessment of a childs nutritional status reveals the child is alert, with shiny hair, firm gums, firm mucous membranes, and regular elimination. This childs nutritional status would be described as: a. Overnourished b. Undernourished c. Well nourished d. Borderline ANS: C Well-nourished children show steady gains in height and weight and have shiny hair, firm gums and mucous membranes, and regular elimination. DIF: Cognitive Level: Analysis REF: dm: 374 OBJ: Objective: 7 TOP: Topic: Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse encourages a Puerto Rican family to bring food to a child because he is not eating the food served on his tray at the hospital. The nurse would expect the child to eat: a. Dried beans mixed with rice b. Crisp vegetables c. Spaghetti and meatballs d. Wild berries, roots, and seeds ANS: A A common food choice of Americans of Puerto Rican descent is dried beans mixed with rice. DIF: Cognitive Level: Analysis REF: dm: 364, Table 15-5 OBJ: Objective: 9 TOP: Topic: Feeding the Ill Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. The nurse recognizes that being able to feed himself is important to the toddler in developing: a. Good nutrition b. A sense of independence c. Adequate height and weight d. Healthy teeth ANS: B By the end of the second year, toddlers can feed themselves. This helps them to develop a sense of independence. DIF: Cognitive Level: Comprehension REF: dm: 373, Table 15-3 OBJ: Objective: 7 TOP: Topic: Feeding the Healthy Child KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 13. To meet Eriksons developmental task of industry, the nurse caring for a 7-year-old would choose an activity such as: a. Working a jigsaw puzzle b. Looking at a comic book c. Playing a competitive board game d. Coloring a picture in a coloring book ANS: A In the developmental period of late childhood, children are striving to develop a sense of industry. The completion of a jigsaw puzzle is industrious play. DIF: Cognitive Level: Analysis REF: dm: 363,Table 15-3 OBJ: Objective: 6 TOP: Topic: Personality Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 14. The nurse recognizes Piagets concrete operational thinking when: a. A 2-year-old says, Its night time when his room is darkened. b. A 4-year-old refers to the hospital as my house. c. A 5-year-old coloring a picture of a puppy says, This is my puppy. d. A 7-year-old says, I am sick because I have germs in my chest. ANS: D The 7-year-olds remark reflecting the cause and effect of germs and illness is an example of operational thinking. All other options are examples of preoperational thought, which is egocentric and symbolic. DIF: Cognitive Level: Analysis REF: dm: 362, Table 15-4 OBJ: Objective: 6 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 15. The nurse has discussed with the mother about introducing solid foods to the 6-month-old infant. The nurse determines that the mother understands the information when she states the first food she will give to the infant is: a. Rice cereal b. Yellow vegetables c. Egg yolks d. Fruits ANS: A Solid foods are usually introduced at about 6 months of age starting with rice cereal, which is the least allergenic. DIF: Cognitive Level: Comprehension REF: dm: 373 OBJ: Objective: 7 TOP: Topic: Feeding the Healthy Child KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 16. When the 8-year-old child comes to the school nurse with his central incisor in his hand and reports he knocked his tooth out on the water fountain, the nurse should: a. Give him an ice cube to suck on. b. Have him wash his mouth out with peroxide and water. c. Wrap the tooth in a clean tissue. d. Wash off the tooth and place it in a container of milk. ANS: D The tooth should be washed off and put in a container of milk to preserve it for possible reimplantation. DIF: Cognitive Level: Application REF: dm: 373 OBJ: Objective: 8 TOP: Topic: Loss of Tooth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 17. The mother of a 7-month-old states, The baby is eating food now. Should I give him regular milk, too? The nurse would respond: a. You should give the baby low-fat milk. b. Try the milk. See if he has any digestive problems. c. Continue breast milk or iron-fortified formula until 1 year of age. d. At this age, infants can tolerate a lactose-free or soy-based milk. ANS: C Whole milk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2 years of age. DIF: Cognitive Level: Application REF: dm: 370 OBJ: Objective: 7 TOP: Topic: Nutrition and Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. When a small group of preschool-age children were playing house, each child was pretending to be a particular family member. The nurse recognizes this as which type of play? a. Parallel b. Cooperative c. Symbolic d. Fantasy ANS: B In cooperative play, children play with each other, each taking a specific role. DIF: Cognitive Level: Analysis REF: dm: 376, Table 15-12 OBJ: Objective: 10 TOP: Topic: Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 19. When the nurse asks the 10-year-old American Indian if he is ready to go to therapy, he does not answer immediately. The nurse assesses this as: a. Indecision b. Considering the answer in silence c. Shyness with strangers d. Fear of medical personnel ANS: B Native Americans value silence. They need to sit and consider matters before replying to questions. DIF: Cognitive Level: Analysis REF: dm: 360, Table 15-2 OBJ: Objective: 9 TOP: Topic: Ethnic Considerations-American Indian KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. A mother tells the nurse, My 11-month-old son is not as active as my other children were at this age. He is the youngest of four and the older children love to dote on him. Which factor is influencing this childs language development? a. Heredity b. Sex c. Mothers health during pregnancy d. Ordinal position ANS: D Motor development of the youngest child may be prolonged if the child is babied by others in the family. DIF: Cognitive Level: Analysis REF: dm: 353 OBJ: Objective: 4 TOP: Topic: Factors Influencing Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 21. The nurse explains that when a mother tells her 4-year-old child that balls should be played with outside and not inside the house, the child is likely to obey the rule because she: a. Does not want to be punished b. Wants to please her mother c. Respects authority figures d. Believes that following the rules is right ANS: A According to Kohlberg, children in the preconventional stage (4 to 7 years) are obedient to their parents for fear of punishment. DIF: Cognitive Level: Analysis REF: dm: 361 OBJ: Objective: 6 TOP: Topic: Moral Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Maintenance and Promotion: Growth and Development 22. When demonstrating a bath procedure to parents of Vietnamese origin, the nurse should avoid: a. Talking directly to the mother b. Exposing the childs genitals c. Touching the childs head d. Using cool water ANS: C The Vietnamese are very sensitive about anyone touching a childs head because that is where consciousness lies. Chapter 7. Newborns and Infants MULTIPLE CHOICE 1. A mother calls the pediatricians office because her infant is colicky. The helpful measure the nurse would suggest to the parent is: a. Sing songs to the infant in a soft voice. b. Place the infant in a well-lit room. c. Walk around and massage the infants back. d. Rock the fussy infant slowly and gently. ANS: D One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements. DIF: Cognitive Level: Application REF: dm: 390 OBJ: Objective: 11 TOP: Topic: Health Maintenance KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse is aware that the age at which the posterior fontanelle closes is: a. 2 to 3 months b. 3 to 6 months c. 6 to 9 months d. 9 to 12 months ANS: A The posterior fontanel closes between 2 and 3 months of age. DIF: Cognitive Level: Knowledge REF: dm: 384, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse knows that an infants birthweight should be tripled by: a. 9 months b. 1 year c. 18 months d. 2 years ANS: B The infant usually triples his or her birth weight by about 12 months of age. DIF: Cognitive Level: Knowledge REF: dm: 386, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse is aware that the age at which an infant is able to sit steadily alone is: a. 4 months b. 5 months c. 8 months d. 15 months ANS: C The infant can sit alone without support at about 8 months of age. DIF: Cognitive Level: Knowledge REF: dm: 382, Figure 16-3 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The infant should be able to walk independently by the age of: a. 8-10 months b. 12-15 months c. 15-18 months d. 18-21 months ANS: B For the majority of children, the milestone of walking alone is achieved between 12 and 15 months. DIF: Cognitive Level: Knowledge REF: dm: 383, Table 16-3 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a cup? The nurse would reply: a. 5 months b. 9 months c. 1 year d. 2 years ANS: A The infant can usually drink from a cup when it is offered at about 5 months. DIF: Cognitive Level: Comprehension REF: dm: 386, Table 16-1 OBJ: Objective: 7 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The nurse would expect a 4-month-old to be able to: a. Hold a cup b. Stand with assistance c. Lift head and shoulders d. Sit with back straight ANS: C Because development is cephalocaudal, of these choices, sitting is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months. DIF: Cognitive Level: Analysis REF: dm: 381, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The abnormal finding in an evaluation of growth and development for a 6-month-old infant would be: a. Weight gain of 4-7 ounces per week b. Length increase of 1 inch in 2 months c. Head lag present d. Can sit alone for a few seconds ANS: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation. DIF: Cognitive Level: Analysis REF: dm: 386, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A parent brings a 6-month-old infant to the pediatric clinic for her well-child examination. Her birthweight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least: a. 12 pounds b. 16 pounds c. 20 pounds d. 24 pounds ANS: B Birth weight is usually doubled by 6 months of age. DIF: Cognitive Level: Application REF: dm: 386, Table 16-1 OBJ: Objective: 8 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The nurse would advise a parent when introducing solid foods to: a. Begin with one tablespoon of the food. b. Mix foods together. c. Eliminate a refused food from the diet. d. Introduce each new food 4 to 7 days apart. ANS: D Only one new food is offered in a 4- to 7-day period to determine tolerance. DIF: Cognitive Level: Comprehension REF: dm: 394 OBJ: Objective: 5 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. When talking with a parent about tooth eruption, the nurse explains that the first deciduous teeth to erupt are the: a. Lower central incisors b. Upper central incisors c. Lower lateral incisors d. Upper lateral incisors ANS: A The first teeth to erupt, usually at about 7 months, are the lower central incisors. DIF: Cognitive Level: Knowledge REF: dm: 387, Table 16-1 OBJ: Objective: 8 TOP: Topic: Development and Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. When assessing development in a 9-month-old infant, the nurse would expect to observe the infant: a. Sitting if supported b. Grasping objects with the palm c. Imitating sounds such as da-da d. Beginning to use a spoon rather sloppily ANS: C The 9-month-old tries to imitate sounds such as da-da or ba-ba. DIF: Cognitive Level: Analysis REF: dm: 388, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. The statement made by a parent that indicates correct understanding of infant feeding is: a. Ive been mixing rice cereal and formula in the babys bottle. b. I switched the baby to low-fat milk at 9 months. c. The baby really likes little pieces of chocolate. d. I give the baby any new foods before he takes his bottle. ANS: D New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods. DIF: Cognitive Level: Analysis REF: dm: 394 OBJ: Objective: 5 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. The nurse would advise a mother who is concerned because her 10-month-old is lethargic, to: a. Keep the babys room well-lit. b. Rub the babys soles vigorously. c. Offer the baby a pacifier. d. Handle the infant slowly and gently. ANS: D Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently. DIF: Cognitive Level: Application REF: dm: 390 OBJ: Objective: 11, 14 TOP: Topic: Health Maintenance KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. The nurse discusses safety-proofing the home with the mother of a 9-month-old. The statement made by the mother that indicates an unsafe behavior is: a. I put covers on all of the electrical outlets. b. In the car, she rides in a front-facing car seat. c. There are locks on all of the cabinets in the house. d. I have a gate at the top and bottom of the stairs. ANS: B A rear-facing infant car seat should be used for infants under 1 year of age. DIF: Cognitive Level: Analysis REF: dm: 396 OBJ: Objective: 13 TOP: Topic: Infant Safety KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. The nurse observes a 10-month-old infant using her index finger and thumb to pick up Cheerios. This behavior is evidence that the infant has developed the: a. Pincer grasp b. Grasp reflex c. Prehension ability d. Parachute reflex ANS: A By 1 year, the pincer-grasp coordination of index finger and thumb is well established. DIF: Cognitive Level: Analysis REF: dm: 382, Figure16-3 OBJ: Objective: 2 TOP: Topic: General Characteristics KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A parent is concerned because her infant has a diaper rash. The nurse would advise the parent to: a. Use commercial diaper wipes to clean the area. b. Apply a protective ointment on the area. c. Change the babys diaper less frequently. d. Keep the diaper area covered all of the time. ANS: B A protective ointment can be applied when the skin in the diaper area appears pink and irritated. DIF: Cognitive Level: Application: Basic Care and Comfort REF: dm: 390 OBJ: Objective: 10 TOP: Topic: Community-Based Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The mother of an infant born prematurely tells the nurse, The baby is irritable. He cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe him? The most appropriate recommendation to help this parent would be: a. Play the radio or TV while you feed the baby. b. Put the baby in a room with sunlight. c. Cover the baby snugly when you hold him. d. Change the babys position quickly. ANS: C A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face. DIF: Cognitive Level: Application REF: dm: 383 OBJ: Objective: 11 TOP: Topic: Community-Based Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. The most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old would be: a. Ride a tricycle. b. Spend time in an infant swing. c. Play with push-pull toys. d. Read large picture books. ANS: C Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child. DIF: Cognitive Level: Analysis REF: dm: 397, Table 16-4 OBJ: Objective: 12 TOP: Topic: Infant Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The statement that indicates the mother of an 8-month-old understands infant sleep patterns is: a. I put the baby in my bed until she falls asleep, then I put her in her crib. b. I let the baby skip an afternoon nap so she will fall asleep earlier. c. I put the pacifier in the crib so she can find it when she wakes up. d. I rock the baby back to sleep if she wakes up at night. ANS: C The parent should assist the infant to develop self-soothing behaviors so the infant can get back to sleep on her own. DIF: Cognitive Level: Analysis REF: dm: 390 OBJ: Objective: 14 TOP: Topic: Health Maintenance KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. The nurse is aware that the 7-month-old can signal feeding readiness by: Select all that apply. a. Pulling spoon toward mouth b. Biting at spoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement at sight of food e. Manipulating finger foods ANS: A, E The 7-month-old pulls the spoon toward its mouth, and can manipulate finger foods. The 7- month-old does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food. DIF: Cognitive Level: Analysis REF: dm: 395, Table 16-4 OBJ: Objective: 2 TOP: Topic: Feeding Skills KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 1. The nurse reminds the parents that the first DPT, oral polio, and flu immunizations should be given when the child is months old. ANS: 2 DIF: Cognitive Level: Comprehension REF: dm: 384, Table 16-1 OBJ: Objective: 2 TOP: Topic: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: The first DPT, polio, and flu immunizations are given at the age of 2 months. 2. The nurse explains the second process of self-mobility a baby learns is seen at the age of 9 months, when the baby begins to . ANS: creep DIF: Cognitive Level: Application REF: dm: 388, Table 16-1 OBJ: Objective: 2 TOP: Topic: Creeping KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: At 7 months the baby begins to crawl, using arms and dragging trunk and legs. At 9 months the baby begins to creep, holding its trunk above the floor. The next self-mobility activity is cruising, where the child walks from one piece of furniture to the next before it begins to walk independently. 3. The nurse cautions parents to place their baby in the or positions, rather than on its stomach, to reduce the risk of sudden infant death syndrome (SIDS). ANS: supine or side-lying DIF: Cognitive Level: Application REF: dm: 390 OBJ: Objective: 10 TOP: Topic: Positions for Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk NOT: Rationale: The supine or side-lying position has been found to reduce possible aspiration, and is believed to reduce the risk of SIDS. OTHER 1. The nurse explains that a babys prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex. a. Hands held open most of the time b. Grasps with thumb on one side and three fingers on the other c. Picks up toy with squeeze action d. Thumb and forefinger hold object e. Hands held closed most of the time ANS: E, A, C, B, D The development advances from the newborns closed hands to the open star hands of the older infant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger. Chapter 8. From Toddlers to Preschoolers MULTIPLE CHOICE 1. Which of these behaviors reported by a parent of an 18-month-old toddler would the nurse report to the pediatrician as a cause for concern? a. The child has temper tantrums. b. The child feeds himself sloppily. c. The child walks by holding onto furniture. d. The child speaks in short sentences. ANS: C By 18 months, a toddler should have been walking alone for several months. The toddler who walks holding onto furniture should be evaluated by a developmental specialist. DIF: Cognitive Level: Analysis REF: dm: 400, Table 17-1 OBJ: Objective: 2 TOP: Topic: Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse assessing growth and development of a 2-year-old child would expect to find: a. That the child jumps with both feet b. That 20 deciduous teeth have erupted c. That the child can hop on one foot d. A vocabulary of 900 words ANS: A The 2-year-old can jump with both feet. The remaining achievements occur after 2 years of age. DIF: Cognitive Level: Analysis REF: dm: 400, Table 17-1 OBJ: Objective: 2 TOP: Topic: Physical Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A parent remarks, My 18-month-old daughter carries her blanket around everywhere. Is this normal? The nurse who has an understanding of toddler development might explain that: a. She carries her blanket because she is ritualistic. b. Carrying her favorite blanket is self-consoling behavior. c. This behavior can be discouraged by offering new toys to the child. d. This could be indicative of emotional distress. ANS: B Favorite possessions and repetitive rituals are self-consoling behaviors for the toddler. DIF: Cognitive Level: Application REF: dm: 403 OBJ: Objective: 6 TOP: Topic: Guidance and Discipline KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse observed three toddlers playing side by side with dolls. Closer observation revealed that the children were not interacting with one another. This type of play would be characterized as: a. Solitary b. Parallel c. Associative d. Cooperative ANS: B Toddlers engage in parallel play. Children play next to, but not with, each other. DIF: Cognitive Level: Analysis REF: dm: 411 OBJ: Objective: 9 TOP: Topic: Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse planning anticipatory guidance for parents of a toddler would include which of the following instructions? a. Adhere to a rigid schedule because the toddler is ritualistic. b. Limit setting should include praise. c. Shoes should fit snugly at the toe and arch. d. Dress the toddler in pants with a zipper so he or she can learn to zip and unzip clothes. ANS: B Limit-setting should include praise as well as disapproval for undesired behavior. DIF: Cognitive Level: Application REF: dm: 403 OBJ: Objective: 2 TOP: Topic: Daily Care KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. The best advice the nurse can offer a parent who is concerned because her 2-year-old is very active and does not eat much is: a. Insist that the child eat one food on the plate. b. Help the child to wind down with a quiet activity before mealtime. c. Maintain a consistent eating schedule for the family. d. Serve the meal with a variety of interesting plates, cups, and utensils. ANS: B Quiet time before meals provides an opportunity for the active toddler to wind down. DIF: Cognitive Level: Application REF: dm: 406 OBJ: Objective: 11 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. How would the nurse advise a parent who states, I never know how much food to feed my child? a. Serving sizes should not exceed 1 teaspoon of each type of food. b. Food quantities must be carefully measured to avoid overfeeding. c. Use 1 tablespoon of each food for each year of age as a guideline. d. A toddler should eat three balanced meals. Snacks are not necessary. ANS: C A tablespoon of each type of food for each year of age is a good guideline to follow when determining serving sizes. DIF: Cognitive Level: Application REF: dm: 406 OBJ: Objective: 11 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The nurse discussing toilet training with parents would identify which of the following as an indicator of readiness? The child is: a. Willing to sit on the potty for 15 to 20 minutes b. Dry in the daytime for 4-hour periods c. Able to communicate that he or she is wet d. Curious about bathroom activities ANS: C Children are ready for toilet training when they can communicate in some fashion that they are wet or need to urinate or defecate. DIF: Cognitive Level: Comprehension REF: dm: 405 OBJ: Objective: 7 TOP: Topic: Toilet Independence KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. The nurse selects the most appropriate toy for a normal 2-year-old child, which is: a. A bicycle with training wheels b. A dump truck c. Wind-up toys d. Legos ANS: B The 2-year-old enjoys playing with objects that can be pushed or pulled. DIF: Cognitive Level: Application REF: dm: 410 OBJ: Objective: 9 TOP: Topic: Toys and Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. To encourage a toddler to practice independence, the nurse would recommend that the childs mother: a. Offer a variety of items to choose from to stimulate his mind. b. Allow the child to determine his own daily routine. c. Offer him a choice between two items. d. Set the routine herself, but discuss with her toddler how he or she would have done it differently. ANS: C The toddler can be allowed to make choices as the situation warrants, but the number of choices should be limited because too many confuse the toddler. DIF: Cognitive Level: Application REF: dm: 399 OBJ: Objective: 3 TOP: Topic: General Characteristics KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. On a home visit, the nurse notes each of the following. The observation that requires teaching intervention to protect the 15-month-old child who lives there is: a. The fireplace has a screen. b. The dining room table has a tablecloth on it. c. There are paintings on the wall. d. The kitchen floor is clean but not shiny. ANS: B A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it. The toddler could be injured if items on the table are moved when the tablecloth is pulled. DIF: Cognitive Level: Analysis REF: dm: 409, Table 17-6 OBJ: Objective: 8 TOP: Topic: Injury Prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. The nurse considers the appropriate snack for a 2-year-old child would be: a. Hot dog sections b. Grapes c. Popcorn d. Applesauce ANS: D Applesauce is a healthy and safe snack food for the toddler. The toddler risks choking on such foods as grapes, hot dogs, and popcorn. DIF: Cognitive Level: Analysis REF: dm: 407 OBJ: Objective: 8 TOP: Topic: Injury Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. The nurse assessing vital signs on a 2-year-old would be concerned about the finding of: a. Temperature 98.8 F b. Pulse 100 beats/min c. Respirations 36 breaths/min d. Blood pressure 90/60 mm Hg ANS: C In the toddler period, the respiratory rate decreases to 25 breaths per minute. DIF: Cognitive Level: Analysis REF: dm: 400 OBJ: Objective: 2 TOP: Topic: Physical Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. When assessing language development in a 2-year-old, an expected finding would be: a. A 900-word vocabulary b. Use of two-word sentences c. Use of pronouns and prepositions d. 100% of speech is understandable ANS: B The 2-year-old should be using two-word sentences. DIF: Cognitive Level: Analysis REF: dm: 403 OBJ: Objective: 5 TOP: Topic: Speech Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse has explained the use of time-outs to the parent of a 3-year-old. The nurse determines the parent understands the information when she states an appropriate period for a time-out is: a. 3 minutes b. 6 minutes c. 10 minutes d. 15 minutes ANS: A Timing for time out is usually based on 1 minute per year of age. DIF: Cognitive Level: Application REF: dm: 403 OBJ: Objective: 10 TOP: Topic: Guidance and Discipline KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The parent of a toddler tells the nurse, My daughters appetite has decreased. Thank goodness she loves to drink milk. The most appropriate response for the nurse to make is: a. Has your daughter been sick recently? b. How much milk does she drink in a day? c. Has she become a fussy eater, too? d. Have you tried offering her finger foods? ANS: B Milk should be limited to 24 ounces a day. Too few solid foods can lead to dietary deficiencies of iron. DIF: Cognitive Level: Analysis REF: dm: 406 OBJ: Objective: 11 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse suggests that bladder training should start when the toddler can stay dry for hours. a. 1 b. 2 c. 3 d. 4 ANS: B If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective. DIF: Cognitive Level: Application REF: dm: 406 OBJ: Objective: 2 TOP: Topic: Bladder Training KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse explains to frustrated parents that a toddler will test their own power with: a. Negativism b. Dawdling c. Tantrums d. Food fads ANS: A By refusing to eat, dress, sleep, or anything else by saying NO, the toddler tests his own power to control. Because toddlers are also egocentric, they come to believe that their negativism is absolute. This is especially true if the adults give into it 19. Which of the following statements best describes the 3-year-old child? a. Boisterous, tattles on others b. Aggressive, shows off c. Helpful, wants to assist with chores d. Talkative, inquisitive about the environment ANS: C Three-year-old children are helpful and can assist in simple household chores. DIF: Cognitive Level: Analysis REF: dm: 418 OBJ: Objective: 3 TOP: Topic: Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis. The nurse would base a response on the knowledge that: a. This behavior indicates a normal curiosity about sexuality. b. Masturbation suggests the boy has an excessive fear of castration. c. It is usually a result of discomfort from a penile rash or irritation. d. The behavior is abnormal and the child should be referred for counseling. ANS: A Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality. DIF: Cognitive Level: Comprehension REF: dm: 418 OBJ: Objective: 17 TOP: Topic: Guidance KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. A preschool-age child is asked, Why do trees have leaves? Which of the following responses would be an example of animism? a. So I can have shade over my sandbox. b. Because God made them that way. c. To hide behind when they are scared. d. For the squirrels to play in. ANS: C Animism describes the tendency of preschool children to attribute human characteristics to nonhuman objects. DIF: Cognitive Level: Comprehension REF: dm: 415 OBJ: Objective: 4 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. The tasks that would be appropriate to expect of a 5-year-old would be: a. Setting the table with paper plates b. Washing the dirty knives c. Carrying glasses from the table to the sink d. Scrubbing out the sink with cleanser ANS: A Parents must consider developmental level and safety when asking the 5-year-old child to help with chores. DIF: Cognitive Level: Analysis REF: dm: 419 OBJ: Objective: 3 TOP: Topic: Development-Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 23. A 3-year-old child, while playing with her favorite toy in the playroom of the pediatric unit, is approached by another child who also wants to play with the same toy. The nurse anticipates that the 3-year-old will: a.layPwell with the other child b. Give the toy up and then not play any more c. Become angry and a physical response might ensue d. Ignore the toy and go on to something else ANS: C The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her possessions. DIF: Cognitive Level: Analysis REF: dm: 419 OBJ: Objective: 6 TOP: Topic: Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. A parent is concerned about her childrens reaction should their grandmother die. In planning a response, the nurse is guided by the understanding that: a. Children are unlikely to notice their grandmothers absence if no one reminds them. b. Young children often understand that other people die, but do not equate it with themselves. c. The childrens response will depend entirely on whether they have been acquainted with death before this. d. Children can understand the concept of a higher being much like adults can. ANS: B Between 3 and 4 years of age, the child becomes curious about death and dying. They may realize that others die, but they do not relate death to themselves. DIF: Cognitive Level: Comprehension REF: dm: 419 OBJ: Objective: 13 TOP: Topic: Concept of Death KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. The intervention that is most effective in dealing with occasional aggression in a 4-year-old child is: a. Have the child take a time-out in the corner for 4 minutes. b. Spank the child at the time of the incident. c. Take away television privileges for the day. d. Send the child to his room for 30 minutes. ANS: A Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique. DIF: Cognitive Level: Application REF: dm: 420 OBJ: Objective: 9 TOP: Topic: Discipline and Limit Setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 26. A parent is concerned about how to make his preschool-age child stop sucking his thumb and asks the nurse for suggestions. The nurses most helpful response would be: a. Most children will stop thumb-sucking naturally by school age. b. Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice. c. Consistently touching the childs fingers whenever he sucks his thumb is most effective. d. Thumb-sucking is detrimental to the eruption of the childs teeth and must be stopped as soon as possible. ANS: A Most children give up the habit of thumb-sucking by the time they reach school. DIF: Cognitive Level: Comprehension REF: dm: 422 OBJ: Objective: 12 TOP: Topic: Thumb-Sucking KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 27. The nurse characterizes the play of 5-year-old children as: a. Rough and tumble play b. Well-organized games c. Following rules d. Prefer inside activities ANS: C The 5-year-old wants to play by the rules but cannot accept losing. The rules may be very strict or change as the game progresses. DIF: Cognitive Level: Comprehension REF: dm: 419 OBJ: Objective: 6 TOP: Topic: Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 28. When discussing preschoolers sexual curiosity with the parent, the nurse determines that the parent understands the information when she states she would: a. Make up funny words for body parts. b. Distract my child with a toy if she asks about sex. c. Answer her questions when she asks. d. Tell her to ask me again when she is 6 years old. ANS: C Parents should provide sex education at the time the child asks about sex. DIF: Cognitive Level: Analysis REF: dm: 426 OBJ: Objective: 12 TOP: Topic: Sexual Curiosity KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 29. In planning care for a moderately retarded child, the type of play most appropriate is: a. Play should exercise leg and arm muscles. b. Play should be educationally oriented to make up for lost time. c. Play should be adjusted to her mental age rather than her chronological age. d. Play is not a necessary component of the care of a mentally retarded child. ANS: C The nurse must consider the childs mental age rather than her chronological age when selecting toys for play. DIF: Cognitive Level: Analysis REF: dm: 425 OBJ: Objective: 6 TOP: Topic: Play KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 30. The nurses best advice to a parent about a preschoolers imaginary friend would be that: a. Imaginary friends is a sign that the child has a low self-esteem. b. It is common for preschoolers to have imaginary friends. c. The preschooler invents an imaginary friend when he feels overwhelmed. d. The best approach to dealing with an imaginary friend is to ignore them. ANS: B Imaginary friends are common and normal during the preschool period and serve many purposes, such as relief from loneliness, mastery of feats, and scapegoat. Chapter 9. School-Age Children MULTIPLE CHOICE 1. The nurse is aware that, in general, the school-age child will: a. Grow 3 to 6 inches/year b. Gain 5 to 7 pounds/year c. Increase head circumference by 1 inch/year d. Reach a visual acuity of 20/20 by 9 years of age ANS: B During the school-age period, the average weight gain per year is generally 5.5 to 7 pounds. DIF: Cognitive Level: Knowledge REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Physical Growth KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse, planning to teach a class on nutrition to fourth-grade students, would keep in mind that school-age children: a. Can concentrate on only one aspect of a situation b. Can think abstractly c. Are egocentric in their thinking d. Think logically and concretely ANS: D Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and an understanding of cause and effect. DIF: Cognitive Level: Analysis REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse explains that the preferred social interaction for the school-age child is based on relationships that are: a. Heterosexual interest groups b. Association with one best friend c. Organized groups like Boy Scouts d. Same-sex peer groups ANS: D The preferred social interaction of the school-age child is in same-sex peer groups or cliques. DIF: Cognitive Level: Analysis REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Social Development, Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse advises the parents of a 10-year-old boy that, according to Eriksons theory, the most developmentally supportive experience for him would be: a. Constant variety of activities b. Successful performance in Little League c. Feeling healthy and strong d. Having a girl friend ANS: B The child who is successful in activities will feel positively about himself or herself. DIF: Cognitive Level: Analysis REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Psychosocial Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent nightmares. The nurses most helpful response is to explain that nightmares are: a. A normal extension of the childs fear of mutilation b. An abnormal response to repressed feelings c. A common result of latent sexuality d. A side effect of overactivity and stimulation ANS: A The nightmares experienced by an 8-year-old are an extension of their characteristic fear of mutilation. DIF: Cognitive Level: Comprehension REF: dm: 438, Table 19-3 OBJ: Objective: 2 TOP: Topic: Eight-Year-Old Nightmares KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. The nurse suggests an appropriate toy for a hospitalized 6-year-old boy would be a: a. Game Boy game b. Compact disc player c. Adventure book d. Jigsaw puzzle ANS: A The 6-year-old child can perform numerous feats that require muscle coordination. At this age, the Gameboy toy will offer nonaggressive competition. DIF: Cognitive Level: Analysis REF: dm: 433 OBJ: Objective: 2 TOP: Topic: Six-Year-Old KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon be starting first grade. The nurse determines that the parents understood the information when the girls father states: a. We should put a stop to her thumb-sucking. b. Well have a talk about what school is like. c. We will let her walk to the bus stop by herself. d. Well have her meet some children who will be in her class. ANS: D To prepare a child for school, parents can arrange for the child to meet other children who will be entering school with her. DIF: Cognitive Level: Application REF: dm: 443, Box 19-2 OBJ: Objective: 3 TOP: Topic: Parental Guidance for Starting School KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. A 9-year-old boy is often cranky and irritable and his school performance has declined. All the options are true about the child. The possible factor causing this behavior is that he: a. Sleeps only 6 to 7 hours a night b. Eats eggs every day c. Has a new dog d. Plays about 1 to 3 hours each evening ANS: A The 9-year-old child requires about 10 hours of sleep per night. DIF: Cognitive Level: Analysis REF: dm: 436 OBJ: Objective: 2 TOP: Topic: Nine-Year-Old Child KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A parent asked the nurse, At what age are children capable of assuming more responsibility for personal belongings? Based on a knowledge of growth and development, the nurse would respond: a. 6 years b. 7 years c. 9 years d. 12 years ANS: C The 9-year-old is dependable and assumes more responsibility for personal belongings. DIF: Cognitive Level: Comprehension REF: dm: 436 OBJ: Objective: 2 TOP: Topic: Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The school nurse who is preserving a tooth that was knocked out on the school yard will be especially careful to: a. Wrap the tooth loosely in a clean cloth. b. Rinse the tooth with alcohol. c. Handle the tooth only by the crown. d. Place the tooth in a warm environment. ANS: C When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage to the root and placed in milk until the child can be examined by a dentist. DIF: Cognitive Level: Application REF: dm: 431 OBJ: Objective: 6 TOP: Topic: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A parent states, My 7-year-old really wants a dog. His 10-year-old brother has allergies to animal dander. I dont know what to do. The nurse could advise this parent to: a. Choose a small breed of dog because the large dogs produce more allergens. b. An older unneutered dog produces fewer allergens than a younger one. c. A cat may be a good choice since it requires less care and is less allergenic. d. Poodles do not shed, making this dog a good choice for people with allergies. ANS: D The poodle breed of dog does not have a shed cycle and so it may be the least offensive pet for the allergic child. DIF: Cognitive Level: Analysis REF: dm: 441 OBJ: Objective: 7 TOP: Topic: Pet Ownership KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. When asked about her activities, a 10-year-old girl responded, I like school. I play the flute in the school band and I take tennis lessons. The nurse knows these activities will help this child develop a sense of: a. Initiative b. Industry c. Identity d. Intimacy ANS: B The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities facilitates the childs sense of industry. DIF: Cognitive Level: Analysis REF: dm: 438, Table 19-3 OBJ: Objective: 2 TOP: Topic: Psychosocial Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. A mother reports that she has a new job and her 12-year-old child is home alone for a time after school. The statement made by the parent, indicating a potentially unsafe situation for this child, is: a. I told him that he could invite a few friends after school. b. I put a list of emergency numbers next to the telephone. c. Last week we made a first aid kit together. d. There is a neighbor available in case of an emergency. ANS: A Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to be home alone in an unsupervised environment is an unsafe situation. DIF: Cognitive Level: Analysis REF: dm: 439 OBJ: Objective: 3 TOP: Topic: Latchkey Children KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A mother is concerned because her 9-year-old has developed the habit of twitching his eyes and flipping his hair while communicating with anyone. The best nursing response to this parent is: a. This may indicate that he needs eyeglasses. b. Children sometimes do these things for attention. c. This behavior suggests low self-esteem. d. Tics appear when a child is under stress. ANS: D The child cannot help such actions and should not be scolded for them because they are mainly a result of tension. DIF: Cognitive Level: Analysis REF: dm: 436 OBJ: Objective: 2 TOP: Topic: Nine-Year-Old Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. A seventh-grade girl tells the school nurse that her art teacher, also a female, is her hero. The most appropriate interpretation of the girls comment is: a. The student may be exploring her career options. b. The comment is cause for concern about sexual abuse. c. The child may have difficulty interacting with her peers. d. Hero worship is a normal phenomenon. ANS: D School-age children tend to admire their teachers and adult companions. For the 11- to 12-year- old, hero worship is a normal phenomenon. DIF: Cognitive Level: Analysis REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Social Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. According to Piaget, a 9-year-old child is in which stage of cognitive development? a. Formal operations b. Preoperational c. Concrete operations d. Sensorimotor ANS: C School-age children are in the concrete operations stage of cognitive development. DIF: Cognitive Level: Knowledge REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse assesses that the 11-year-old has moved from the mind set of egocentrism when he says: a. I am a member of the best Cub Scout group in the world. b. I must do my homework before I can play. c. My dad can do anything! d. Im sorry. I bet that hurt your feelings. ANS: D The ability to see anothers point of view indicates moving away from egocentrism into a more altruistic mind set. DIF: Cognitive Level: Analysis REF: dm: 429 OBJ: Objective: 5 TOP: Topic: Increasing Understanding KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. When the school-age child becomes frustrated with a school assignment and says, I cant do this!, the parent should: a. Ask, What is it that is so difficult? b. Allow the child to quit the effort. c. Call in older siblings to help. d. Finish the project for him. ANS: A Helping the child focus on the problem that is keeping him from mastery can limit frustration. Quitting or having someone else finish is detrimental to the development of industry. DIF: Cognitive Level: Analysis REF: dm: 429 OBJ: Objective: 2 TOP: Topic: Industry KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. The nurse, in attempting to help a 7-year-old girl express her feelings about being in a new school, would prompt the child with basic feeling words, such as: Select all that apply. a. Mad b. Glad c. Sad d. Scared e. Jealous ANS: A, B, C, D The words mad, glad, sad, and scared are basic feeling words that can prompt a young child to better express his or her feelings. DIF: Cognitive Level: Application REF: dm: 440 OBJ: Objective: 2 TOP: Topic: Expression of Feelings KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation COMPLETION 1. The nurse advises the parents of a 6-year-old to try and ensure at least hours of sleep daily. ANS: 11 DIF: Cognitive Level: Comprehension REF: dm: 434 OBJ: Objective: 2 TOP: Topic: Sleep Needs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: The 6-year-old school-age child needs at least 11 hours of sleep. 2. The nurse reminds the parents who are trying to select a dog for their allergic child that the best selection would be a female dog that is and . ANS: young, neutered DIF: Cognitive Level: Comprehension REF: dm: 441 OBJ: Objective: 7 TOP: Topic: Pet Selection for Allergic Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: Young, neutered female dogs produced less allergens. 3. When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse cautioned the teacher to be alert for symptoms of that can be carried by the reptiles. ANS: Salmonella DIF: Cognitive Level: Comprehension REF: dm: 440, Table 19-14 OBJ: Objective: 7 TOP: Topic: Salmonella KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: Geckos can infect humans with Salmonella. 4. The pediatric nurse assesses the child who has been diagnosed with diabetes to ensure that he does to come to believe that his disease is a form of . ANS: punishment Chapter 10. Adolescents MULTIPLE CHOICE 1. When assessing a 13-year-old boy, the nurse would keep in mind physical changes in the pubertal male, beginning with: a. Development of axillary and facial hair b. Enlargement of pectoral muscles c. Enlargement of testicles d. Voice changes ANS: C In boys, pubertal changes begin with enlargement of the testicles and internal structures. DIF: Cognitive Level: Comprehension REF: dm: 447 OBJ: Objective: 4 TOP: Topic: Physical Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A 13-year-old boy states, The girls in my class tower over me. The nurses most informative response would be: a. It may seem that way because girls have a growth spurt 2 years earlier than boys. b. Perhaps your parents are not exceptionally tall. c. Boys usually experience a growth spurt 1 year earlier than girls. d. You may feel short, but you are actually average height for your age. ANS: A Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlier for girls than for boys. DIF: Cognitive Level: Application REF: dm: 445 OBJ: Objective: 4 TOP: Topic: Physical Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A parent comments that her adolescent daughter seems to be daydreaming a lot these days. The nurse understands that this behavior indicates she is: a. Bored b. Not getting enough rest c. Trying to block out stress and anxiety d. Mentally preparing for real situations ANS: D Daydreaming allows adolescents to act out in their imaginations what will be said or done in certain situations. This helps them to prepare for and cope with interactions with others. DIF: Cognitive Level: Analysis REF: dm: 453 OBJ: Objective: 4 TOP: Topic: Development-Daydreams KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse planning a safety program for high school students should understand that most accidental deaths in adolescence are related to: a. Firearms b. Automobiles c. Drowning d. Diving injuries ANS: B The chief safety hazard for the adolescent is automobiles. DIF: Cognitive Level: Knowledge REF: dm: 458 OBJ: Objective: 11 TOP: Topic: Safety KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A 16-year-old excitedly tells his parents that he was offered a part-time job. Which response represents an effective problem-solving approach for his parents? a. Your studies are too important for you to have a part-time job. b. When we went to high school, academics were the teenagers priority. c. We want you to put your earnings in a savings account. d. How do you think you will manage your school work and a job? ANS: D An effective approach to help adolescents learn to solve problems is for parents to guide them in exploring alternatives. DIF: Cognitive Level: Application REF: dm: 454 OBJ: Objective: 11 TOP: Topic: Parenting KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. One psychosocial task of adolescence on which the nurse must focus when planning care, is the development of a sense of: a. Initiative b. Industry c. Identity d. Involvement ANS: C Psychosocial milestones that must be accomplished during adolescence include the five Imsiage of self, identity, independence, interpersonal relationships, and intellectual maturity. DIF: Cognitive Level: Knowledge REF: dm: 445, Box 20-1 OBJ: Objective: 2 TOP: Topic: Psychosocial Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. A 13-year-old female tells the school nurse that she is getting fat, especially in her hips and legs. The understanding by the nurse that would best guide the response is: a. Many teenagers are unaware of proper nutrition. b. Teenagers of this age become less active and should eat fewer calories. c. Puberty is often preceded by fat deposits in these areas. d. As soon as menarche occurs, she will lose this excess weight. ANS: C Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips, thighs, and breasts, causing them to enlarge. DIF: Cognitive Level: Analysis REF: dm: 449, Box 20-2 OBJ: Objective: 4 TOP: Topic: Physical Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The school nurse is planning a program for girls about the physical changes of puberty; this program should be directed to girls of the age: a. 16 years b. 14 years c. 12 years d. 10 years ANS: D Because puberty can occur in girls as early as age 10 years, instruction must be given by that age. DIF: Cognitive Level: Comprehension REF: dm: 454 OBJ: Objective: 4 TOP: Topic: Physical Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. The statement made by a parent indicating understanding about helping a 13-year-old manage allowance money is: a. I set amounts he can earn for particular chores. b. I give him a certain amount of money for each day. c. I put money into his bank account each month. d. I told him to ask me when he needs money. ANS: A If money is simply handed out as requested, it is difficult to develop responsibility for finances and money management. The older adolescent is able to get a job. The younger teen can earn money by doing particular chores. DIF: Cognitive Level: Application REF: dm: 453 OBJ: Objective: 4 TOP: Topic: Development-Responsibility KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The nurse suggests a good dietary source of zinc for an adolescent who is a vegetarian would be: a. Green, leafy vegetables b. Citrus fruits c. Nuts d. Enriched breads ANS: C Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources include nuts, legumes, and wheat germ. DIF: Cognitive Level: Comprehension REF: dm: 457 OBJ: Objective: 9 TOP: Topic: Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. An adolescents parent comments, My son seems so preoccupied with his appearance these days. Is this normal? The nurses best response would be: a. It is his attempt to express his individualism. b. His preoccupation with his looks is quite normal. c. He is probably troubled with his physical changes. d. This shows that he has a positive self-image. ANS: B Preoccupation with self-image is normal and accounts for the constant primping of teenagers. DIF: Cognitive Level: Application REF: dm: 445 OBJ: Objective: 4 TOP: Topic: Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. Foods that would be a healthy choice for an adolescent who just finished playing in a strenuous game would be: a. Cheeseburger and soda b. Hot fudge sundae c. Two Egg McMuffins and orange juice d. Bagel and skim milk ANS: D A bagel provides a rapid supply of carbohydrates to the muscles, and skim milk provides a slow release of carbohydrates to the muscles. DIF: Cognitive Level: Application REF: dm: 457 OBJ: Objective: 9 TOP: Topic: Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. When planning to answer a 16-year-old girls questions about menstruation, the nurse must consider cognitive development. According to Piaget, the cognitive aspect that is developed during adolescence is the ability to: a. View a situation from multiple perspectives b. Focus more on the past than present situations c. Exercise concrete reasoning d. Consider hypothetical situations ANS: D According to Piaget, in the formal operations stage adolescents have the ability to think abstractly. DIF: Cognitive Level: Comprehension REF: dm: 445, Box 20-1 OBJ: Objective: 4 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A girl tells the nurse that she and her best friend belong to the popular clique. She states, I love Britney Spears and I want to be a singer. The nurse recognizes the girls statement as characteristic of peer relationships in: a. Early adolescence b. Middle adolescence c. Late adolescence d. Entire adolescent period ANS: A Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent. DIF: Cognitive Level: Comprehension REF: dm: 452 OBJ: Objective: 4 TOP: Topic: Social Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse is leading a discussion group with parents of adolescents. One parent comments, My son cant do anything without checking with his friends first. My opinion doesnt count anymore. The nurse would formulate a response on the knowledge that this behavior is: a. Unusual for adolescent boys b. Often more apparent in boys than girls c. A normal phenomenon during adolescence d. Suggestive of feelings of low self-worth ANS: A Parents may need help understanding that the teenagers exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family. DIF: Cognitive Level: Application REF: dm: 452 OBJ: Objective: 4 TOP: Topic: Peer Relationships KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The nurse points out to a group of parents that the most positive developmental significance of a peer group to the adolescent is that the group serves as: a. A social outlet b. An association to blur personal identity c. A platform for group think d. An initial separation from family ANS: D Being a member of a peer group and communicating with and seeking approval from this group are the first separation from the family. DIF: Cognitive Level: Analysis REF: dm: 461 OBJ: Objective: 10 TOP: Topic: Peer Groups KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse understands that the adolescents avid sexual orientation to be based on Freuds theory, which describes adolescence as the stage. a. Conceptual b. Genital c. Glandular d. Pubertal ANS: B Freud describes the adolescent period as genital. DIF: Cognitive Level: Knowledge REF: dm: 445, Box 20-1 OBJ: Objective: 3 TOP: Topic: Freud KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse using the PACE interview guide for persons at risk for substance abuse arrives at a score of 2 for an adolescent patient. The nurse should assess this score as: a. Nonindicative of potential substance abuse b. Normal experimentation of the adolescent c. Need to schedule another PACE interview in 3 months d. Indication for referral for counseling ANS: D The PACE guide recommends that a score of 2 or higher would suggest the need for a referral for counseling about substance abuse. DIF: Cognitive Level: Knowledge REF: dm: 445 OBJ: Objective: 4 TOP: Topic: PACE Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. The nurse explains that the restlessness seen in the adolescent is, in part, attributable to: Select all that apply. a. Drive to be accepted by society as an individual b. Surge for independence c. Establishment of a personal identity d. Intense libido e. Rapid body changes ANS: A, B, C, D, E All the options listed are sources of stress to the adolescent and are stimulants to restlessness. DIF: Cognitive Level: Comprehension REF: dm: 444 OBJ: Objective: 2 TOP: Topic: Sources of Stress for the Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse teaching a seminar on teen pregnancy tells the parents that they should be alert for indications of a child concealing a pregnancy with such behaviors as: Select all that apply. a. Wearing baggy clothes b. Wearing excessive makeup c. Dieting to lose weight d. Seeking privacy e. Ostentatiously purchasing tampons ANS: A, C, E Wearing of concealing clothing, dieting to lose weight, and conspicuous advertising of a menstrual period are indicators of a hidden pregnancy. Wearing of excessive makeup and seeking privacy are normal adolescent behaviors. DIF: Cognitive Level: Analysis REF: dm: 460, Box 20-5 OBJ: Objective: 12 TOP: Topic: Signals of Concealed Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse considers the rites of passage that are valued by the adolescent in American society, which are: Select all that apply. a. Attaining legal drinking age b. Selection of a career c. Religious affiliation d. Obtaining a drivers license e. High school graduation ANS: A, D, E Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, drivers license, and matriculation through high school are such signals. Religious affiliation and selection of a career path do not necessarily signal adulthood. Chapter 11. Respiratory Disorders MULTIPLE CHOICE 1. The nurse tells the parents of a child who has a positive throat culture for group A hemolytic streptococcus that the treatment most likely will be: a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until his sore throat is gone d. Streptococcus immunization ANS: B When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished. DIF: Cognitive Level: Application REF: 575 OBJ: 27 TOP: Acute Pharyngitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. The initial intervention that the nurse would suggest to the parents of a child experiencing laryngeal spasm is to: a. Take the child outside in the cool air. b. Bring the child directly to the emergency department. c. Put the child in the bathroom with a hot shower running. d. Have the child drink plenty of fluids. ANS: C The child experiencing laryngeal spasm should be placed in a high-humidity environment such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm. DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 576 OBJ: 8 TOP: Croup Syndromes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse would observe a child for frequent swallowing following a tonsillectomy and adenoidectomy (T & A) because this is indicative of: a. Bleeding from the surgical site b. Pain at the incision area c. Sore throat from postnasal drip d. Potential vomiting ANS: A Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing. DIF: Cognitive Level: Comprehension REF: 579 OBJ: 19 TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 4. The best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy is: a. Popsicle b. Chocolate milk c. Orange juice d. Cola drink ANS: A Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated. DIF: Cognitive Level: Analysis REF: 581 OBJ: 19 TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. The 4-month-old child in the emergency department shows extreme dyspnea, a croaking inspiration, and excessive drooling. Based on these observations alone, the nurses initial intervention would be to: a. Sit the child upright and notify the physician. b. Start oxygen by mask and keep the child flat. c. Apply a cold compress to the throat. d. Assess the back of the throat for obstruction. ANS: A These are the classic signs of epiglottitis. If epiglottitis is suspected, the nurse should not examine the back of the throat because laryngospasm may occur followed by respiratory arrest. The child should be made as comfortable as possible and the physician should be summoned. Epiglottitis is a medical emergency. DIF: Cognitive Level: Analysis REF: 576 OBJ: 12 TOP: Epiglottitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, would expect to find: a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases ANS: C The child experiencing an acute asthma attack will wheeze as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced. DIF: Cognitive Level: Knowledge REF: 582 OBJ: 13, 14 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse caring for a child experiencing an acute asthma attack would include: a. Offering plenty of fluids, particularly carbonated beverages b. Placing the child in a humidified cool mist tent with oxygen c. Administering sedatives as ordered to decrease anxiety d. Positioning the child with arms resting on the overbed table ANS: D This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea. DIF: Cognitive Level: Comprehension REF: 583 OBJ: 14 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse explains to the parent of a child with exercise-induced asthma that Cromolyn, an antiinflammatory drug, should be inhaled: a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day ANS: A Antiinflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the attack in progress. They are meant to be used as prophylactic therapies. DIF: Cognitive Level: Analysis REF: 584 OBJ: 14, 15 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in their families has CF. The nurses response is based on the understanding that with CF: a. Only one parent carries the CF gene. b. Both parents are carriers of the CF gene. c. The inheritance pattern is multifactorial. d. The result is probably a genetic mutation. ANS: B Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease. DIF: Cognitive Level: Analysis REF: 587 OBJ: 20 TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The statement indicating that the childs parents understand how to perform respiratory therapy is: a. We do her postural drainage before the aerosol therapy. b. We give her respiratory treatments when she is coughing a lot. c. We give the aerosol followed by postural drainage before meals. d. She needs respiratory therapy everyday when she has an infection. ANS: C Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting. DIF: Cognitive Level: Analysis REF: 589 OBJ: 20 TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. To facilitate digestion and absorption of nutrients, the nurse teaches the child with cystic fibrosis that she needs to take: a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Salt supplements ANS: A An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the childs body cannot produce. DIF: Cognitive Level: Knowledge REF: 594 OBJ: 20 TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The nurse would advise a mother to clear the nostrils when her infant has a cold by: a. Clearing the nasal passages after the infant has a feeding b. Using over-the-counter nose drops to clear passages c. Removing nasal secretions with a bulb syringe d. Instilling saline nose drops after clearing away secretions ANS: C The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe. DIF: Cognitive Level: Application REF: 574 OBJ: N/A TOP: Nasopharyngitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse offers a variety of fluids to compensate for the fluid loss through dyspnea. Appropriate fluids would be: a. Room temperature water b. Carbonated beverages c. Iced fruit juice d. Cold milk ANS: A Room temperature fluids are the best. Carbonated and iced beverages increase spasm Milk stimulates mucus production. DIF: Cognitive Level: Analysis REF: 585 OBJ: 14 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. The asthmatic child who has been taking theophylline complains of stomach ache and tachycardia and is sweating profusely. The nurse recognizes these symptoms as: a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity ANS: D The symptoms described are the signs of theophylline toxicity. DIF: Cognitive Level: Analysis REF: 584 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Significant information would be to: a. Wrap the infant snugly for rest periods. b. Position the infant prone for sleep. c. Sit the baby up in an infant seat. d. Place infants on their back or side for sleep. ANS: D The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS. DIF: Cognitive Level: Application REF: 595 OBJ: 16 TOP: Sudden Infant Death Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16. An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is: a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear/anxiety related to dyspnea and hospitalization ANS: B An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection. DIF: Cognitive Level: Analysis REF: 577 OBJ: 9 TOP: Respiratory Syncytial Virus KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Physiological Integrity 17. The nurse explains that a ventricular septal defect will: a. Allow blood to shunt left to right, causing increased pulmonary flow and no cyanosis b. Allow right-to-left shunt, causing decreased pulmonary flow and cyanosis c. Allow no shunting because of high pressure in the left ventricle d. Allow increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume ANS: A Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis. DIF: Cognitive Level: Analysis REF: 598 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect, is: a. A loud, harsh murmur with a systolic tremor b. Cyanosis when crying c. Blood pressure higher in the arms than in the legs d. A machinery-like murmur ANS: A A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect. DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 599 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is: a. Blood pressure is higher on the right side. b. Blood pressure is higher on the left side. c. Blood pressure is lower in the arms than in the legs. d. Blood pressure is lower in the legs than in the arms. ANS: D The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation. DIF: Cognitive Level: Analysis REF: 599 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse is caring for a toddler with acute laryngotracheobronchitis. The assessment finding that would indicate the child is experiencing increased respiratory obstruction is: a. Restlessness b. Tachycardia c. Brassy cough d. Expiratory wheezing ANS: C Restlessness is a primary sign of increased respiratory obstruction. DIF: Cognitive Level: Analysis REF: 576 OBJ: 5 TOP: Acute Croup KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting: a. Increases the return of venous blood back to the heart b. Decreases arterial blood flow away from the heart c. Is a common resting position when a child is tachycardic d. Increases the workload of the heart ANS: A The squatting position allows the child to breathe more easily because systemic venous return is increased. DIF: Cognitive Level: Analysis REF: 600 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because: a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion. b. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia. c. Blood is shunted past cardiac arteries, causing myocardial hypoxia. d. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart. ANS: A When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation. DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 599 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. An appropriate nursing action related to the administration of Lanoxin to an infant would be: a. Counting the apical rate for 30 seconds before administering the medication b. Withholding a dose if the apical heart rate is less than 100 beats/min c. Repeating a dose if the child vomits within 30 minutes of the previous dose d. Checking respiratory rate and blood pressure before each dose ANS: B As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified. DIF: Cognitive Level: Application REF: 603 OBJ: 23 TOP: Congestive Heart Failure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 24. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are: a. The coronary arteries b. The heart muscle and the mitral valve c. The aortic and pulmonic valves d. The contractility of the ventricles ANS: B The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved. DIF: Cognitive Level: Knowledge REF: 604 OBJ: 26 TOP: Rheumatic Fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. He is always hungry. b. He tires out during feedings. c. He is fussy for several hours every day. d. He sleeps all the time. ANS: B Fatigue during feeding or activity is common to most infants with congenital cardiac problems. DIF: Cognitive Level: Analysis REF: 596 OBJ: 23 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How does Kawasaki disease affect my childs heart and blood vessels? The nurses response is based on the understanding that: a. Inflammation weakens blood vessels, leading to aneurism. b. Increased lipid levels lead to the development of atherosclerosis. c. Untreated disease causes mitral valve stenosis. d. Altered blood flow increases cardiac workload with resulting heart failure. ANS: A Inflammation of vessels weakens the walls of the vessels and often results in aneurysm. DIF: Cognitive Level: Analysis REF: 607 OBJ: N/A TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the parent understood the instructions when he states: a. If the baby turns blue, I will hold him over my shoulder with his knees bent up toward his chest. b. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body. c. If the baby turns blue, I will immediately put the baby upright in an infant seat. d. If the baby turns blue, I will put the baby in a squatting position. ANS: A In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee- chest position. DIF: Cognitive Level: Application REF: 600 OBJ: 22 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 28. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? The nurse bases a response on the understanding that clubbing occurs as a result of: a. Untreated congestive heart failure b. A left-to-right shunting of blood c. Decreased cardiac output d. Chronic hypoxia ANS: D Clubbing of the fingers develops in response to chronic hypoxia. DIF: Cognitive Level: Analysis REF: 604 OBJ: 22 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints and carditis c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate ANS: B The presence of two major Jones criteria would indicate a high probability of rheumatic fever. DIF: Cognitive Level: Analysis REF: 604, Box 25-3 OBJ: 26 TOP: Rheumatic Fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 30. An infant with congestive heart failure is receiving Lanoxin. The nurse recognizes signs of digoxin toxicity, which are: a. Restlessness b. Decreased respiratory rate c. Increased urinary output d. Vomiting ANS: D Symptoms of digoxin toxicity include the following: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse. DIF: Cognitive Level: Analysis REF: 604 OBJ: 23 TOP: Congestive Heart Failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse describes the allergic salute as a cluster of signs related to chronic allergy, which are: Select all that apply. a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva ANS: A, B, C, E The allergic salute does not include a productive cough. DIF: Cognitive Level: Comprehension REF: 582 OBJ: 10 TOP: Allergic Salute KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse would suggest to the parents of an asthmatic child to encourage participation in such activities as: Select all that apply. a. Swimming b. Gymnastics c. Baseball d. Basketball e. Tennis ANS: A, B, C Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion. DIF: Cognitive Level: Application REF: 585 OBJ: 13 TOP: Sports Activities Suitable for Asthmatics KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse explains that the can sense the oxygen concentration in the blood and can signal the brainstem to increase respiration. ANS: chemoreceptors DIF: Cognitive Level: Comprehension REF: 573 OBJ: 3 TOP: Chemoreceptors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: Chemoreceptors can sense the oxygen concentration of the blood and can signal the brainstem to increase and deepen respirations in order to keep an adequate supply of oxygen in the circulating volume. 2. After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the nurse explains that routine immunizations will need to be delayed for months. ANS: 9 Chapter 12. Cardiovascular Disorders Multiple Choice 1. The right ventricle is responsible for: 1. Pumping blood to the left atrium. 2. Pumping deoxygenated blood to the lungs. 3. Pumping oxygenated blood to the body. 4. Returning oxygenated blood from the lungs. ANS: 2 Feedback 1.The ventricle pumps blood to the lungs via the pulmonary artery. 2.The right ventricle pumps blood to the lungs to become oxygenated. 3.The left ventricle pumps oxygenated blood to the body. 4.The pulmonary artery returns the oxygenated blood from the lungs. 2. The heart valve that connects the left atria and the left ventricle is: 1. The tricuspid valve. 2. The bicuspid valve. 3. The pulmonic valve. 4. The aortic valve. ANS: 2 Feedback 1. This valve connects the right atria to the right ventricle. 2. This valve connects the left atria and the left ventricle. 3. This valve connects the right ventricle and the pulmonary artery. 4. This valve connects the left ventricle and the ascending aorta. 3. In fetal development, the is open to allow blood to flow in the heart. 1. Patent ductus arteriosus 2. Pulmonic valve 3. Aortic valve 4. Bicuspid valve ANS: 1 Feedback 1. The patient ductus arteriosus is the opening in the heart that allows blood to flow in the heart. 2. The pulmonic valve is not the opening. 3. The aortic valve is open before and after birth. 4.The bicuspid valve is open before and after birth. 4. A nurse is assessing a 4-year-old child with a known atrial septal defect. Identify what the nurse should expect to see in the assessment. 1. An increased heart rate 2. An increased respiratory rate 3. Lower oxygen saturation 4. A lower heart rate ANS: 3 Feedback 1.The heart rate will be a normal rate for a 4-year-old child. 2.The respiratory rate will be a normal rate for a 4-year-old child. 3. Oxygen saturations are expected to be lower because of the leakage caused by the defect. 4. The heart rate will be a normal rate for a 4-year-old child. 5. A nurse is discussing heart disorders that cause the mixing of oxygenated and deoxygenated blood with a new nurse. The nurse should explain that the mixed disorders consist of all of the following except: 1. Tetralogy of Fallot. 2. Hypoplastic left heart. 3. Truncus afteriosus. 4. Transposition of the great vessels. ANS: 1 Feedback 1. This is an obstructive disorder. 2. A mixed blood heart defect 3. A mixed blood heart defect 4. A mixed blood heart defect 6. When assessing a newborn, a nurse should check capillary refill: 1. On the fingernail beds. 2. On the sternum. 3. On the arm. 4. On the hand. ANS: 2 Feedback 1. Because of peripheral cyanosis, the fingernail beds will not respond quickly for an adequate measurement of capillary refill. 2. The sternum responds quickly for an adequate measurement of capillary refill. 3. The hand does not respond quickly for an adequate measurement of capillary refill. 4. The hand does not respond quickly for an adequate measurement of capillary refill. 7. Weak peripheral pulses can indicate: 1. A weak heart. 2. Poor cardiac output. 3. Hypertension. 4. Patent ductus arteriosus. ANS: 2 Feedback 1.The heart may be weak, but does not indicate that the pulses will be weak. 2.A lower amount of output does not allow for peripheral pulses to be easily felt. 3.If the patient has hypertension, the pulses may be bounding. 4.Patent ductus arteriosus may have bounding pulses. 8. Identify the child that is demonstrating acrocyanosis. 1. A newborn shows slow capillary refill. 2. A newborns hands are blue following delivery. 3. A newborn with a fever has red hands. 4. A newborn with a lack of oxygen has blue hands. ANS: 2 Feedback 1. Slow capillary refill can be demonstrated with acrocyanosis, but is not the cause. 2. The vasoconstriction after birth is a cause of acrocyanosis 3.A newborn with a fever will not demonstrate acrocyanosis. 4.Lack of oxygen will cause central cyanosis. 9. A newborn is born with patent ductus arteriosus. If the patent ductus arteriosus does not close during this time, the newborn will exhibit: 1. Narrowing pulse pressures. 2. Widening pulse pressures. 3. A decreased heart rate. 4. Quick capillary refill. ANS: 2 Feedback 1. The pulse pressures widen because of the low pressure gradient within the heart. 2. The widening occurs because of the low pressure gradient within the heart. 3. The heart rate will increase because of not perfusing to the lungs. 4. The capillary refill will be sluggish because the oxygenated blood is not going out to the rest of the body. 10. A nurse is assessing a newborn with a known patent ductus arteriosus defect of the heart. The mother asks when she can start breastfeeding her infant. The best explanation by the nurse would be: 1. The newborn will need to have the defect repaired before oral feedings can start. 2. The newborn will need to have extensive rest time between feedings, so plan on breastfeeding one time, then we will give a nasogastric feeding the next time. 3. The nursing staff will monitor the newborn during feedings because she may sweat and have increased difficulty breathing. 4. The newborn should have no issues while breastfeeding. ANS: 3 Feedback 1. Feedings can begin before the repair if the newborn does not demonstrate difficulties in cardiac and respiratory status. 2. Rest time will be needed before and after feedings, but there is no need to alternate between breast and nasogastic feedings. 3. Monitoring will enable the nurse to assess when the newborn needs a break in feedings. 4. The newborn will have some issues with feedings because of the heart issues. 11. A 6 month old has a known diagnosis of an Atrial Septal Defect (ASD). The nurse would anticipate all except which of the following during an assessment? 1. Shortness of breath 2. Enlarged liver 3. Poor feeding 4. A diastolic murmur ANS: 4 Feedback 1. Shortness of breath is expected since more blood flows to the pulmonary area because of the hole. 2. The liver enlarges because of the increase in blood flow. 3. Poor feedings are expected as a result of shortness of breath because of the pulmonary hypertension issues. 4.A systolic murmur is expected due to the blood being forced through the pulmonary valve. 12. A nurse should question which of the following orders for a child with a known ASD? 1. A transesophogeal ultrasound 2. Digoxin 3. EKG 4. All are appropriate orders for a child with an ASD. ANS: 4 Feedback 1. The ultrasound allows for the entire heart to be viewed in order to find the exact location of the ASD. 2. Digoxin will help with the cardiac output. 3.An EKG will help identify heart function. 4.All the orders would be appropriate for the child because each aids in gathering all the information needed for proper treatment of the defect. 13. A nurse knows that the mother understands the discharge instructions for an 8 month old that had a cardiac catheterization for an ASD when the mother states: 1. We will need to schedule weekly visits to make sure the heart is functioning properly. 2. The surgical site will require us to keep our child in isolation at home. 3. We will need to monitor the insertion site for drainage and temperature changes. 4. My child will not have any more issues with arrhythmias. ANS: 3 Feedback 1. The visits will need to be prescribed by the doctor. Visits usually take place three months to one year after the procedure area heals. 2. The child will have a short recovery time and does not need to be in isolation. 3. The insertion site must be monitored for signs and symptoms of infection and bleeding. 4. The child may have arrhythmias his/her entire life. 14. The most common heart defect is: 1. ASD. 2. Patent Foramen Ovale (PFO). 3. Hypertrophic left heart syndrome. 4. Ventricular Septal Defect (VSD). ANS: 4 Feedback 1. An ASD is not a common heart defect. Usually see closure within a few hours after birth. 2. The PFO is common in premature neonates. Not common in full-term neonates thus is not the most common defect. 3.A rare heart congenital heart defect. 4.The most common defect. The defect can be medically managed with minimal intervention. 15. A nurse is assessing a child with a known VSD. The nurse anticipates auscultating: 1. A systolic thrill in the lower left sternal border. 2. Wet lung sounds bilaterally. 3. A diastolic thrill in the upper left sternal border. 4. A diastolic wetness in the right sternal border. ANS: 1 Feedback 1.A thrill sound in the left sternal border will be heard because of where the valve is located. 2.The lung sounds should be clear. 3.A systolic thrill and lower left sternal border thrill will be noted. 4.A thrill sound in the left sternal border with diastolic sounds will be heard because of where the valve is located. 16. An 18 month old with known Tetralogy of Fallot is seen squatting after running in the hospital playroom. The nurse knows the child is: 1. Having a rapid drop in the amount of oxygen in the blood and is short of breath. 2. Having a bowel movement. 3. About to faint because of the lack of oxygen in his blood. 4. Mimicking others in the playroom. ANS: 1 Feedback 1.Squatting allows the child to take breaths and gain oxygen. 2.The child is attempting to inhale oxygen quickly. 3. The child is maintaining a position to gain oxygen in order to prevent fainting. 4. The child is squatting in order to take deep breaths and gain oxygen after the playing. 17. Jaycob, a 24-month-old child with a diagnosis of RSV and Tetrology of Fallot, is being cared for by a new nurse. Jaycob is agitated and is crying when care is provided. He begins to drop his oxygen saturations below an acceptable range. The nurse should: 1. Have the parent console the child. 2. Feed the child. 3. Call the doctor for an order for a sedative. 4. Cluster the care and allow the child time to rest. ANS: 4 Feedback 1. The question does not state that the parent is available. 2. Feeding the child may cause oxygen saturations to drop lower. 3.All attempts at consoling the child should first be provided before asking for a sedative. 4.Clustering cares will allow for time to rest and result in less stress for the child. 18. A newborn with a diagnosis of Tetrology of Fallot is demonstrating heart failure. The doctor orders a prostaglandin E1 drip. The nurse knows this is used to: 1. Maintain blood flow to the lungs. 2. Open the patent foramen ovale. 3. Increase blood flow to the extremities. 4. Decrease resistance of blood flow through the heart. ANS: 1 Feedback 1. The prostaglandin will allow the Patent Ductus Arteriosis to have patency. 2. The patent foramen ovale is already open when a Tetrology of Fallot is present. 3. Blood flow to the heart and lungs rather than the extremities is the priority. 4. Because of the holes in the heart, the resistance is already low. 19. A nurse caring for a child with Eisenmengers syndrome should assess for all of the following except: 1. Fatigue. 2. Acrocyanosis. 3. Shortness of breath. 4. Blood pressure. ANS: 2 Feedback 1. The child will have increased fatigue due to the lack of oxygen in the body. 2. The child will have cyanosis. 3. The child will demonstrate a shortness of breath because of the lack of oxygen being perfused to the lungs. 4. The blood pressure should be assessed to monitor how the heart is pumping. 20. ECHMO is commonly used as a treatment for a baby with which defect/syndrome? 1. Eisenmengers syndrome 2. Coarctation of the aorta 3. ASD 4. Tetralogy of Fallot ANS: 1 Feedback 1. ECHMO acts as a bypass for the heart and lungs to obtain enough oxygen for the body. 2. ECHMO acts as a bypass for the heart and lungs to obtain enough oxygen for the body. In coarctation, the heart and lungs are able to perfuse. 3. ECHMO acts as a bypass for the heart and lungs to obtain enough oxygen for the body. 4. ECHMO acts as a bypass for the heart and lungs to obtain enough oxygen for the body. 21. A child with a known diagnosis of coarctation of the aorta will have an increase in: 1. Blood pressure in the lower extremities. 2. Blood pressure in the upper extremities. 3. Blood pressure in the heart. 4. Blood pressure in the aortic arch. ANS: 2 Feedback 1. Because of the low flow of blood, the lower extremities will have a lower flow of blood. 2. The upper extremities will demonstrate an increase in blood pressure. 3.The blood pressure affects the extremities. 4.The blood pressure affects the extremities. 22. A nurse is assessing a child with coarctation of the aorta. The nurse knows she will find all the following except: 1. Decreased femoral pulses. 2. A report of chest pain. 3. Shortness of breath. 4. Poor growth. ANS: 2 Feedback 1. The decreased blood flow to the lower extremities is noted in coarctation by assessing the pulses. 2. Coarctation can be asymptomatic. 3. Shortness of breath may be noted when exerting the body. 4.The child will have a slower growth rate than peers. 23. When assessing a child with coarctation of the aorta, the nurse should perform assessments to all of the follow areas except: 1. Blood pressure in all of the extremities. 2. Monitoring the perfusion to the extremities. 3. Pre-assessment for Digoxin before giving the prescribed doses. 4. Assessing the narrowing pulse pressures. ANS: 4 Feedback 1. Blood pressure will greatly differ in the upper extremities versus the lower extremities. 2. Perfusion to the lower extremities will be worse than in the upper extremities. 3. Digoxin should always have a pre-assessment of an apical pulse for one minute. 4. Pulse pressures do not give adequate data for a child with coarctation of the aorta. 24. A common bacteria that causes scarring on the aortic valve is: 1. Group A streptococcus bacteria. 2. Group B streptococcus bacteria. 3. Staphylococcus aureus. 4. E. coli. ANS: 1 Feedback 1.This common bacteria causes scarring on the aortic valve. 2.This is not a common bacteria in the heart. 3. Common in endocarditis, but not a common cause of scarring on the aortic valve. 4. Usually attacks the GI tract 25. Identify a common characteristic of pulmonary atresia. 1. Acrocyanosis at birth 2. Weight gain is similar to that of well newborns. 3. A murmur will be noted with an ASD or a PDA. 4. Severe cyanosis will be present at birth. ANS: 4 Feedback 1.Cyanosis will be noted at birth. 2.Weight gain will be slower than peers. 3.A murmur will not be present with the ASD and the PDA. 4.Cyanosis will be noted at birth because of the fistula not allowing blood to go to the lungs in order to oxygenate. 26. Pulmonary stenosis causes an increased workload on: 1. The left atrium. 2. The right ventricle. 3. The left ventricle. 4. The right atrium. ANS: 2 Feedback 1. This type of stenosis occurs in the right ventricle. 2. The right ventricle has an increased workload because of the lack of blood being pushed out of the heart. 3. The left ventricle does not have the workload because it is pushing oxygenated blood to the body. 4. The right atrium is filling with blood and does not have the resistance to push it to the lungs, thus decreasing the workload. 27. The nurse is assessing a baby with a known diagnosis of Tetralogy of Fallot with pulmonary atresia. The nurse should expect which of the following in her assessment of the baby? 1. A VSD murmur 2. Normal growth and development 3. Decreased peripheral pulses 4. Profound cyanosis ANS: 4 Feedback 1.PDA murmur is common, not a VSD. 2.Growth and development will be delayed. 3.Peripheral pulses will be bounding. 4.Cyanosis will be present due to where the holes in the heart are located. 28. An 18-pound, 12-month-old child with a known diagnosis of Tetralogy of Fallot with pulmonary atresia has been ordered to receive a calorie intake of 150 calories/kg per day. The total caloric intake prescribed is: 1. 1528 2. 1227 3. 2700 4. None of the above ANS: 2 18/2.2= 8.18 kg 8.18 kg x 150 calories= 1227 calories per day Feedback 1. Too many calories per day 2. Adequate calories per day 3. Too many calories per day 4. One answer is correct. 29. When a child with transposition of the greater vessels is assessed, the nurse should anticipate that: 1. The lower extremities will have bounding pulses. 2. Cyanosis will be noted when the child is sleeping on his/her back. 3. An ASD murmur will be present. 4. The oxygen saturations in the upper extremities will be lower than the oxygen saturations in the lower extremities. ANS: 4 Feedback 1.The extremities will have weak pulses and low oxygen saturations. 2.Cyanosis will be present when crying. 3. The child will have a PDA. 4. The difference in oxygenation is caused by the aorta receiving deoxygenated blood. 30. A newborn with transposition of the grater arteries has been prescribed Captopril. The mother asks why the child needs to be on such a medication. The best response by the nurse would be: 1. Your child needs the beta-blocker to decrease the angiotensin in the body. 2. The medication will help decrease the shortness-of-breath episodes. 3. The medication is an antihypertensive that helps relax the coronary arteries. 4. Your child is not responding to the prostaglandin E drip, so the Captopril needs to be started to decrease the blood pressure. ANS: 3 Feedback 1. The medication is an ACE inhibitor. 2. The medication will not alter the respiratory rate. 3. The medication is an antihypertensive and relaxes the coronary arteries to help decrease blood pressure. 4.A prostaglandin E drip is not a long-term solution. Chapter 13. Neurological and Sensory Disorders MULTIPLE CHOICE 1. A parent comments that her infant has had several ear infections in the past few months. The nurse understands that infants are more susceptible to otitis media because: a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure. c. They have increased susceptibility to upper respiratory tract infections. d. The eustachian tube is short, straight, and wide. ANS: D An infants eustachian tubes are shorter, wider, and straighter, allowing microorganisms easy access to the middle ear. DIF: Cognitive Level: Knowledge REF: 511 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse determines a mother understands instructions about administering an oral antibiotic for otitis media when the mother verbalizes that she will: a. Continue using the medication until symptoms are relieved. b. Share the medicine with siblings if their symptoms are the same. c. Give the medication with a glass of milk. d. Administer prescribed doses until all the medication is used. ANS: D Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated. DIF: Cognitive Level: Application REF: 522 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. The situation in which the nurse would be suspicious about a hearing impairment is: a. A 3-month-old infant with a positive Moro reflex b. A 15-month-old toddler who is babbling c. An 18-month-old toddler who is speaking one-syllable words d. A 24-month-old toddler who communicates by pointing ANS: D The child who is not making verbal attempts by 18 months should undergo a complete physical examination. DIF: Cognitive Level: Analysis REF: 523 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The best way for the nurse to communicate with a 10-year-old child who has a hearing impairment would be to: a. Use gestures and signs as much as possible. b. Let the childs parents communicate for her. c. Face the child and speak clearly in short sentences. d. Recognize that the childs ability to communicate will be on a 6-year-old level. ANS: C The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality. DIF: Cognitive Level: Application REF: 523 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes would include: a. Keep the infant flat after feeding. b. Give over-the-counter anticongestants. c. Avoid getting water in the ears. d. Clean the ear canal with cotton-tipped applicators. ANS: C Following a tympanostomy, care should be taken to avoid getting water in the ears. DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2 TOP: Postoperative Care of Tympanostomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The school nurse would suspect amblyopia when the child: a. Has a reddened sclera in one eye b. Covers one eye to read the board c. Complains of a headache d. Has copious tears while watching TV ANS: B Indicators of amblyopia include covering one eye to see, tilting the head to see, missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, it is too vague to point suspicion to any disorder. DIF: Cognitive Level: Analysis REF: 526 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. The nurse explains that a common treatment for amblyopia is: a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractory muscles to rest c. Using glasses that will slightly blur the image for the good eye d. Using corticosteroids to treat inflammation of the optic nerve ANS: A Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors. DIF: Cognitive Level: Knowledge REF: 526 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The school nurse recognizes the cardinal sign of a hyphema when she assesses: a. Opacity of the lens b. A yellow-white reflex on the pupil c. A dark-red spot in front of the iris d. Inflamed mucous membranes of the eyelids ANS: C A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury. DIF: Cognitive Level: Knowledge REF: 527 OBJ: N/A TOP: Retinoblastoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parents to have their children immunized against Reyes syndrome. c. Avoid giving salicylate-containing medications to a child who has viral symptoms. d. Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy. ANS: C Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms. DIF: Cognitive Level: Application REF: 529 OBJ: 11 TOP: Reyes Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The nurse caring for a 5-month-old with viral influenza suspects the development of Reyes syndrome when the child: a. Has respirations drop from 18 to 14 breaths/min b. Goes to sleep after feeding c. Suddenly vomits d. Develops a macular rash ANS: C A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in LOC. A 5-month-old child that sleeps after eating is normal. DIF: Cognitive Level: Application REF: 529 OBJ: 11 TOP: Reyes Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. The nurse explains that febrile seizures: a. Occur when the body temperature exceeds 103F b. Can be prevented by anticonvulsant medication c. Usually lead to the development of epilepsy d. Occur when the temperature rises quickly ANS: D Febrile seizures occur in response to a rapid rise in temperature, often above 102F (38.8C). DIF: Cognitive Level: Comprehension REF: 533 OBJ: 9 TOP: Febrile Seizures KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A parent reports that her child experiences episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Akinetic c. Myoclonic d. Complex partial ANS: A Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and which may last only a few seconds. DIF: Cognitive Level: Analysis REF: 534, Table 23-2 OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. An adolescent has just had a generalized seizure lasting 1 minute. Following the seizure, the nurse should: a. Help the patient to sit upright b. Turn on the side c. Offer ice chips d. Assist to ambulate ANS: B During the tonic phase of a generalized seizure, the head, legs, and back stiffen. DIF: Cognitive Level: Analysis REF: 534, Table 23-2 OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing action would be to: a. Guide the child to the floor if the child is standing, and then go for help. b. Move objects out of the childs immediate area. c. Stick a padded tongue blade between the childs teeth. d. Manually restrain the child. ANS: B During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury. DIF: Cognitive Level: Application REF: 534, Table 23-2 OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 15. A child had a generalized tonic-clonic seizure that lasted 90 seconds. After a generalized tonic-clonic seizure, the nurse would expect that the child might be: a. Restless b. Sleepy c. Nauseated d. Anxious ANS: B Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness. DIF: Cognitive Level: Analysis REF: 535 OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The nurse would include in a teaching plan pertinent to the long-term administration of Dilantin that: a. The medication should be given with food to reduce gastrointestinal distress. b. Behavioral changes are a possible side effect. c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored. ANS: C Dilantin can cause gum overgrowth, which can be minimized by regular massaging. DIF: Cognitive Level: Application REF: 536 OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed ANS: C Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated. DIF: Cognitive Level: Analysis REF: 536 OBJ: 10 TOP: Cerebral Palsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The assessment finding that should be reported immediately if observed in a child with meningitis is: a. Irregular respirations b. Tachycardia c. Slight drop in blood pressure d. Elevated temperature ANS: A Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure. DIF: Cognitive Level: Analysis REF: 530 OBJ: 15 TOP: Meningitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. The nurse recognizes this posture as: a. Correct anatomical position b. Decorticate c. Decerebrate d. Opisthotonos ANS: C In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only. DIF: Cognitive Level: Analysis REF: 542 OBJ: 14 TOP: Posturing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse giving instructions for acute conjunctivitis would teach parents to: a. Apply cool compresses to the affected eye several times a day. b. Instill topical steroid eye drops for 1 week. c. Clear away drainage from the inner to the outer aspect of the eye. d. Keep the eye patched until the inflammation resolves. ANS: C Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction). DIF: Cognitive Level: Application REF: 526 OBJ: N/A TOP: Conjunctivitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. A child is brought to the emergency department after he fell and hit his head on the ground. The nursing assessment that suggests the child has a concussion is: a. Sleepy but easily arousable b. Complaining of a stiff neck c. Cannot remember what happened to him d. Pupils react sluggishly to light ANS: C A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury. DIF: Cognitive Level: Analysis REF: 543 OBJ: N/A TOP: Head Injury KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches that are worse in the morning with vomiting. The nurse would suspect: a. Meningitis b. Reyes syndrome c. Brain tumor d. Encephalitis ANS: C The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased ICP with the hallmark symptoms of headache, vomiting, drowsiness, and seizures. DIF: Cognitive Level: Analysis REF: 532 OBJ: 15 TOP: Brain Tumor KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The pediatric nurse is alerted to the probability of an ear infection in a 6-month-old child when the baby: Select all that apply. a. Is hypersensitive to noise b. Is irritable c. Has a reddened ear canal d. Rolls head from side to side e. Spikes a temperature of 103F ANS: B, D, E Infants signal ear infections by being irritable, spiking a temperature, rolling their heads from side to side, and pulling at or rubbing their ears. DIF: Cognitive Level: Application REF: 521 OBJ: 2 TOP: Indications of Ear Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse cautions parents that hearing impairment can affect the childs: Select all that apply. a. Speech clarity b. Language development c. Emotional stability d. Personality development e. Academic achievement ANS: A, B, C, D, E All the options are areas in which a hearing impairment could interfere with normal development. DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse, preparing air travel instructions to prevent barotraumas in infants, would include: Select all that apply. a. Using ear plugs during takeoff b. Holding baby upright during flight c. Omitting the meal just before takeoff d. Letting the baby nurse during descent e. Applying ear drops before takeoff ANS: D Encouraging an infant to swallow reduces the pressure in the ears during descent. DIF: Cognitive Level: Comprehension REF: 524 OBJ: 2 TOP: Barotrauma KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse caring for a child with infectious meningitis, would include in the care: Select all that apply. a. Isolation precautions b. Provision of dimly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions ANS: A, B, C, D, E All elements of nursing care listed in the options would be part of comprehensive care of a child with meningitis. Chapter 14. Mental Health Disorders MULTIPLE CHOICE 1. When a parent asks the nurse to describe what is meant by a learning disability, the nurses most helpful response would be: a. A child may have difficulty with perception, language, comprehension, or memory. b. It is characterized by inattention, impulsiveness, and hyperactivity. c. The childs intellectual ability limits his learning. d. The child has difficulty learning because of brain damage. ANS: A Learning disability is an educational term. Children with learning disabilities may have average to above-average intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization. DIF: Cognitive Level: Application REF: 739 OBJ: 2 TOP: Learning Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 2. What would be the appropriate response to an adolescent who states, This has been the worst day of my life? a. You should focus your mind on positive thoughts. b. Everybody has a bad day now and then. c. Youre young. What could be so terrible? d. Tell me about the worst day in your life. ANS: D The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and giving the adolescent full attention. DIF: Cognitive Level: Application REF: 735, NCP 32-1 OBJ: 3 TOP: Suicide KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im not going to talk about that! Its none of your business, anyway! Leave me alone! The nurse recognizes that the outburst was stimulated by the fact that the adolescent is: a. Acting out and needs to be brought under control so the conference can continue b. Trying to shift the focus of the conference away from himself, and the nurse needs to refocus c. Demonstrating that this problem requires the assistance of a psychiatrist d. Responding to the discrediting of his parents, which causes anxiety in the child; thus reassurance is needed that blame will not be directed at anyone ANS: D Discrediting parents threatens the childs security and creates anxiety. DIF: Cognitive Level: Comprehension REF: 730 OBJ: 4 TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. The nurse answering phone calls at a local suicide prevention hotline would recognize the statement indicating the greatest risk of suicide is: a. I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself. b. My parents arent home and wont be back for 4 hours. That should be enough time for the pills to work. Ive got a hundred of them. c. My dad will be home first, so hell find me. So I think Ill use his gun. I hope he didnt lock the cabinet. d. My girlfriend is here with me. She told me to call because I was talking crazy about killing myself. ANS: B The risk of death increases when there is a definite plan of action, the means are readily available, and the person has few resources for help and support. DIF: Cognitive Level: Analysis REF: 764 OBJ: 3 TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 5. The nurse assesses an early sign of depression in a 15- year-old boy who previously was active in a band, and had saved his money to buy a special guitar when he: a. Gives up the band to spend time with his girlfriend b. Spends all of his time at the library studying in order to qualify for the honor society c. Gives his guitar away and spends his time listening to music in his room d. Withdraws all of his money out of the bank to buy an expensive leather jacket ANS: C A major depression is characterized by a prolonged behavioral change from baseline that interferes with school, family life, and age-specific activities, frequently signaled by giving prized possessions away. DIF: Cognitive Level: Analysis REF: 733 OBJ: 3 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 6. A mother is concerned because her teenage son is always in trouble for fighting at school and always seems to be angry. She mentions that her husband drinks a bit. The understanding guiding the nurses response is: a. The boy is displaying antisocial behavior and should be evaluated for mental illness. b. He is displaying one of the typical defense patterns of children of alcoholics and should receive immediate treatment. c. The mother is displaying her own anger with her husbands drinking, and she needs immediate intervention. d. This boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention. ANS: D Early recognition of and intervention for children of alcoholics are paramount. This adolescent is using the coping pattern of acting-out behaviors to deal with the family situation. DIF: Cognitive Level: Comprehension REF: 738 OBJ: 9 TOP: Substance Abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. The school nurse suggests to the classroom teacher that the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder would be: a. Seat the child in the back of the room to prevent distractions for other children. b. Pair the child with a student buddy to offer reminders to pay attention. c. Divide work assignments into shorter periods with breaks in between. d. Separate the child from others to increase his focus on schoolwork. ANS: C The child with attention deficit hyperactivity disorder needs breaks between periods of work and study. DIF: Cognitive Level: Application REF: 739, Box 32-2 OBJ: 11 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 8. The nurse explains that the person who is bulimic: a. Is severely underweight b. Alternates binge eating with purging c. Is an introverted perfectionist d. Has extremely close family relationships ANS: B Bulimia is characterized by alternating binge eating and purge behavior. DIF: Cognitive Level: Knowledge REF: 740 OBJ: 12 TOP: Bulimia KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 9. A 14-year-old girl with obsessive-compulsive disorder tells the nurse other teens tease her because she washes her hands many times during the school day. The nurse is aware that this disorder puts the adolescent at greater risk for: a. Anorexia nervosa b. Suicidal behavior c. Attention deficit hyperactivity disorder d. Learning disability ANS: B OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for adolescents with OCD. DIF: Cognitive Level: Comprehension REF: 732 OBJ: N/A TOP: Obsessive-Compulsive Disorder KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 10. The statement made by a parent of an adolescent with anorexia nervosa indicating an understanding of this condition is: a. There really isnt anything to worry about. Dont they say you can never be too thin? b. My daughter just doesnt have much of an appetite. c. She is just trying to punish me for divorcing her father. d. She seems to see herself as fat, even though her weight is below normal. ANS: D Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes. DIF: Cognitive Level: Application REF: 740, Figure 32-2 OBJ: 12 TOP: Anorexia Nervosa KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 11. An appropriate nursing intervention for a hospitalized child who is autistic would be to: a. Place the child in a location where she can watch all of the activity on the unit. b. Use the childs chronological age as a guide for communication. c. Keep the childs room free of toys or objects that she might want to take home with her. d. Organize care to provide as few disruptions to the routine as possible. ANS: D During hospitalization, the nurse should provide a highly structured environment with few distractions for a child who is autistic. DIF: Cognitive Level: Application REF: 732 OBJ: N/A TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 12. A nurse planning to speak with a parent support group about childhood autism would include the information: a. Significant signs of the disorder manifest by 1 year of age. b. The earliest signs of autism are impulsivity and overactivity. c. Autism is usually diagnosed when the child goes to elementary school. d. Medications can cure childhood autism. ANS: A Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are significant signs of dysfunction by 1 year of age. DIF: Cognitive Level: Application REF: 732 OBJ: N/A TOP: Autism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 13. An adolescent is brought to the emergency department after an automobile accident. When the nurse approaches the adolescent, he becomes combative. The nurse notes his speech is slurred and his gait is ataxic. The nurse suspects the adolescent has used: a. Alcohol b. Cocaine c. Amphetamines d. PCP ANS: A Behavioral signs of alcohol ingestion include slurred speech, short attention span, drowsiness, combativeness, and violence. DIF: Cognitive Level: Analysis REF: 736, Table 32-1 OBJ: 7 TOP: Substance Abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 14. When the nurse is collecting a nursing history, an adolescent states that she has tried speed. The nurse recognizes this as the street name for: a. Barbiturates b. Cocaine c. Methamphetamine d. Marijuana ANS: C Speed is the street name for methamphetamine. DIF: Cognitive Level: Knowledge REF: 737, Table 32-2 OBJ: 7 TOP: Substance Abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. The nurse explains that the member of the child guidance team who is a medical doctor with special training in psychoanalytic theory is the: a. Psychiatrist b. Psychoanalyst c. Psychologist d. Counselor ANS: A The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a psychologist. The psychologist is not a medical doctor, and neither is the counselor. DIF: Cognitive Level: Application REF: 731 OBJ: 5 TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 16. Because young children cannot express themselves well, the nurse uses the therapeutic intervention that allows children to act out their feelings, which is: a. Art therapy b. Play therapy c. Music therapy d. Bibliotherapy ANS: B Play therapy allows a young child to act out with dolls or figures concerns that the child may be unable to adequately express verbally. DIF: Cognitive Level: Comprehension REF: 731 OBJ: 1 TOP: Play Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic child, but has the negative aspect of: a. Sedating the child b. Impairing cognition c. Causing hypotension d. Creating fluid retention ANS: B Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the potential of self-injuring behavior. DIF: Cognitive Level: Application REF: 732 OBJ: 2 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. A 9-year-old has been admitted to the hospital after huffing lighter fluid. The nurse should assess for: a. Depressed respirations b. Severe vomiting c. Frightening hallucinations d. Elevation of temperature ANS: A Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and general sensorium. DIF: Cognitive Level: Application REF: 735 OBJ: 7 TOP: Substance Abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physical Integrity: Reducing Risk 19. As the pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate, the nurse assesses possible dyslexia when the child: a. Becomes hyperactive and ceases to read b. Reads the word GOD as DOG c. Makes up a story rather than reading the text d. Stutters as he reads ANS: B Dyslexics often transpose a word as they read; for example, the word is GOD, but it appears to the dyslexic child as the word DOG. DIF: Cognitive Level: Application REF: 739 OBJ: N/A TOP: Dyslexia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection MULTIPLE RESPONSE 1. The nurse describes the members of a mental health team for child guidance as including a: Select all that apply. a. Psychiatrist b. Pediatrician c. Psychologist d. Dietitian e. Social worker ANS: A, B, C, E The traditional members of the child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team. DIF: Cognitive Level: Comprehension REF: 731 OBJ: 5 TOP: Members of the Child Guidance Team KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 2. The school nurse cautions a group of parents about the prevalence of children who get high by inhaling hydrocarbons and fluorocarbons, such as: Select all that apply. a. Glue b. Chlorine c. Cleaning fluid d. Copy machine toner e. Aerosol sprays ANS: A, C, E Although there are many products that could be inhaled, the most frequently used products are glue, cleaning fluid, aerosol sprays, Freon, shoe polish, and gasoline products. DIF: Cognitive Level: Application REF: 736, Table 32-1 OBJ: 7 TOP: Inhaling Hydrocarbons KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse takes into consideration in planning the care of an adolescent with anorexia nervosa that the cause of this disorder is: Select all that apply. a. Discomfort relative to emerging sexuality b. Fear of intimacy c. Pervasive low self-esteem d. Egocentricity e. Inability to meet developmental needs ANS: A, B, C, D, E All options listed are considered to be the cause of anorexia nervosa. DIF: Cognitive Level: Application REF: 740 OBJ: 12 TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation COMPLETION 1. The nurse documents that every time the child is directed to discuss the relationship with her brother, she complains of shortness of breath and begins to have asthma-like symptoms. The nurse assesses this behavior as a reaction. ANS: psychosomatic DIF: Cognitive Level: Analysis REF: 731 OBJ: 1 TOP: Psychosomatic Reaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation NOT: Rationale: A psychosomatic reaction is one in which a dysfunction of the body has an emotional or mental cause. 2. The nurse assists with the intervention of therapy, which provides a physical and social environment that is stable and therapeutic. ANS: milieu Chapter 15. Gastrointestinal Disorders MULTIPLE CHOICE 1. The finding in a newborn assessment suggestive of tracheoesophageal fistula is: a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen ANS: B After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first feeding is introduced. DIF: Cognitive Level: Analysis REF: 635 OBJ: 2 TOP: Esophageal Atresia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. An acid-base imbalance that the nurse would expect to occur from this persistent vomiting is: a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis ANS: D Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting. This results in alkalosis. DIF: Cognitive Level: Analysis REF: 641 OBJ: N/A TOP: Vomiting KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse makes all of the assessments listed below. The assessment that indicates that the treatment is not effective is: a. Weight loss of 4 ounces b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle ANS: A Weight loss is the most significant indicator of dehydration. DIF: Cognitive Level: Analysis REF: 647-648 OBJ: 5 TOP: Dehydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse is aware that rapid respirations are a possible cause of dehydration because they: a. Prevent the child from drinking b. Increase circulation, thus increasing urine production c. Cause evaporation of fluid on the mucous membranes d. Often lead to vomiting ANS: C Rapid respirations cause increased insensible fluid loss. DIF: Cognitive Level: Comprehension REF: 647 OBJ: 5 TOP: Dehydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. An appropriate intervention for a 3-month-old infant who has gastroesophageal reflux is to: a. Position the infant in the crib on its abdomen, with the head elevated. b. Administer medication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infant in an infant seat after feedings. ANS: A After feedings, the infant is placed in a prone position to avoid increased intraabdominal pressure. DIF: Cognitive Level: Application REF: 642 OBJ: 3 TOP: Gastroesophageal Reflux KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse interviewing parents of an infant with pyloric stenosis would expect the parents to report the infant has had: a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation ANS: B Vomiting is the outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting. DIF: Cognitive Level: Application REF: 636 OBJ: 2 TOP: Pyloric Stenosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. A parent reports that her child has been scratching the anal area and complaining of itching. Based on this information, the nurse might suspect this child has: a. Pinworms b. Giardiasis c. Ringworm d. Roundworm ANS: A With pinworms, the nurse or parent may notice that the child scratches the anal area and complains of itchiness. The other choices do not cause this reaction. DIF: Cognitive Level: Analysis REF: 652 OBJ: 7 TOP: Worms KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse that is teaching a parent about pyrvinium (Povan) would include the information that the drug will cause: a. Diarrhea b. Skin rash c. Red stool d. Metallic taste ANS: B The nurse should advise parents that Povan stains and turns stools red. DIF: Cognitive Level: Application REF: 652 OBJ: 7 TOP: Worms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The instruction the nurse would give to parents about preventing the spread and reinfection of pinworms is: a. Keep childrens nails short b. Dress child in loose-fitting underwear c. Clean the bathroom with bleach solution d. Wash bed linens in cold water ANS: A One intervention to prevent the further spread of pinworms is to keep the childs fingernails short. Pinworms are not spread from person to person. DIF: Cognitive Level: Application REF: 653 OBJ: 7 TOP: Worms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. A parent reports that her 2-year-old child experiences constipation frequently. The nurse would recommend to the mother to include in the childs diet: a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt ANS: C Dietary modifications for constipation include eating more high-roughage foods such as whole- grain breads and cereals. DIF: Cognitive Level: Application REF: 643 OBJ: N/A TOP: Constipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Intussusception would be suspected when parents describe the childs stools as: a. Currant jelly b. Black and tarry c. Green liquid d. Greasy and foul-smelling ANS: A Bowel movements of blood and mucus that contain no feces (currant jelly stools) are common about 12 hours after the onset of the obstruction. DIF: Cognitive Level: Comprehension REF: 640 OBJ: N/A TOP: Intussusception KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. The nurse explains that the treatment of choice for a child with intussusception is: a. A barium enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage ANS: A A barium enema is the treatment of choice for intussusception because the passage of the barium frequently un-telescopes the bowel. Surgery is scheduled only if reduction is not achieved. DIF: Cognitive Level: Knowledge REF: 640 OBJ: N/A TOP: Intussusception KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Parents ask the nurse how their infant developed a Meckels diverticulum. The nurses response is based on the knowledge that this condition occurs when: a. The yolk sac remains connected to the intestine. b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear. d. There is a weakness in the abdominal wall. ANS: C If the vitelline duct fails to disappear completely after birth, a blind pouch may form. DIF: Cognitive Level: Knowledge REF: 640 OBJ: 2 TOP: Meckels Diverticulum KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. An infant is admitted to the hospital with severe isotonic dehydration. In planning the infants care, the nurse is aware the infant is at risk for: a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock ANS: D Shock is the greatest threat to life in isotonic dehydration. DIF: Cognitive Level: Analysis REF: 647 OBJ: 5 TOP: Dehydration KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A child is brought to the emergency department because he ingested an unknown quantity of Tylenol. After gastric lavage is completed, the nurse might expect this child to receive: a. Activated charcoal b. N-Acetylcysteine c. Vitamin K d. Syrup of ipecac ANS: B Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen. DIF: Cognitive Level: Application REF: 654 OBJ: 10 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. The nurse, planning a parent education program about lead poisoning prevention, would include the information that the sources of lead in the community are most likely: a. Increased lead content of air b. Use of aluminum cookware c. Deteriorating paint in older buildings d. Inhaling smog ANS: C The primary source of lead is paint from old, deteriorating buildings. DIF: Cognitive Level: Knowledge REF: 656 OBJ: 11 TOP: Lead Poisoning KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. A frightened mother calls a neighbor because her child swallowed dishwashing detergent. The most appropriate action that the neighbor can advise is: a. Induce vomiting by giving the child syrup of ipecac. b. Take the child to the local emergency department. c. Give the child activated charcoal mixed with juice. d. Give the child milk to soothe affected mucous membranes. ANS: B Inducing vomiting is no longer recommended because it may pose additional problems. The child should be taken immediately to the nearest emergency department. DIF: Cognitive Level: Knowledge REF: 653 OBJ: 9 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. A child has been diagnosed with ascariasis (roundworm). The statement made by her mother that may suggest a cause for her condition is: a. Ive been airing out the house on these nice breezy days. b. My child often goes out to the garden and pulls up a carrot to eat. c. She runs barefoot so much I have to wash her feet at least twice a day. d. We just remodeled our bathroom at home. ANS: B The child can ingest roundworm eggs from contaminated soil. DIF: Cognitive Level: Analysis REF: 653 OBJ: N/A TOP: Worms KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. The nurse would expect the stools of a child with celiac disease to have which appearance? a. Ribbonlike b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling ANS: C Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption. DIF: Cognitive Level: Analysis REF: 638 OBJ: N/A TOP: Celiac Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. After reviewing dietary restrictions for celiac disease, the nurse determines that a parent understands the information when she states that a grain that can be eaten by a child with celiac disease is: a. Wheat b. Oats c. Barley d. Rice ANS: D Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. DIF: Cognitive Level: Knowledge REF: 638 OBJ: N/A TOP: Celiac Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. The priority goal of the infants care is to prevent: a. Fluid and electrolyte imbalance b. Nutritional deficiency c. Skin breakdown d. Malabsorption ANS: A The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance. DIF: Cognitive Level: Comprehension REF: 641 OBJ: N/A TOP: Gastroenteritis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. The nurse, speaking to the parent of a 3-year-old child who has mild diarrhea, would advise the dietary modification of: a. Soft diet with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution such as Pedialyte d. Chicken soup because it is high in sodium ANS: C An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel movements. DIF: Cognitive Level: Application REF: 663 OBJ: 6 TOP: Diarrhea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse would expect a child admitted to the hospital for nonorganic failure to thrive to: a. Cry to be picked up b. Be limp like a rag doll c. Be responsive to cuddling d. Weigh in the 10th percentile for age ANS: B Some children with failure to thrive have rag-doll limpness (hypotonia) and appear wary of their caregivers. DIF: Cognitive Level: Analysis REF: 649 OBJ: N/A TOP: Failure to Thrive KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. Nursing interventions for the mother of a 10-month-old infant with nonorganic failure to thrive would include: a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative characteristics of the infant with the mother c. Having the nurse provide as much of the infants care as possible d. Teaching the mother about the developmental milestones to expect in the next few months ANS: D The nurse can increase parents knowledge of growth and development by providing anticipatory guidance about normal developmental milestones. DIF: Cognitive Level: Application REF: 650 OBJ: N/A TOP: Failure to Thrive KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 25. The statement by a mother that may indicate a cause of her sons vitamin C deficiency is: a. We get our fruits from homemade preserves. b. We use milk from our own goats. c. We raise all our own vegetables. d. Were not big meat eaters. ANS: A Vitamin C is destroyed by heat. DIF: Cognitive Level: Analysis REF: 651 OBJ: N/A TOP: Scurvy KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. The nurse instructing a mother how to administer oral nystatin suspension, prescribed to treat thrush, would teach to: a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa. ANS: D An appropriate way to administer nystatin is to moisten a sterile applicator with the medication and then swab it on the inside of the mouth. DIF: Cognitive Level: Application REF: 652 OBJ: N/A TOP: Thrush KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 27. One reason that infants are more vulnerable to fluid and electrolyte imbalances than adults is that: a. They have a smaller surface area than adults in proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water. ANS: C A greater percentage of body water is contained in the extracellular compartment of children under 2 years of age. DIF: Cognitive Level: Knowledge REF: 647 OBJ: 5 TOP: Dehydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. An infant is admitted to the hospital with severe dehydration. Laboratory results show pH 7.32, PaCO2 40, HCO3 21. The nurse interprets these values as: a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A A pH lower than 7.35 indicates acidosis. If the childs pH falls in the same line as the HCO3-, the problem is metabolic (see Table 27-4). DIF: Cognitive Level: Application REF: 643 OBJ: N/A TOP: Fluid and Electrolyte Imbalance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. When feeding a child with pyloric stenosis, the nurse will: Select all that apply. a. Give a formula thinned with water. b. Burp the baby before and during feeding. c. Give the feeding slowly. d. Refeed if the baby vomits. e. Position baby on left side after feeding. ANS: B, C, D Children with pyloric stenosis are given formula thickened with cereal; the baby is burped before and during feeding to get rid of any gas in the stomach; the baby is fed slowly and refed if vomiting occurs. The baby is positioned on the right side to allow the weight of the feeding to stay in the stomach against the pyloric valve. DIF: Cognitive Level: Application REF: 636 OBJ: 4 TOP: Pyloric Stenosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 1. The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for a baby with gastroenteritis, recognizes that this confirms the process that is part of this disease. ANS: inflammatory DIF: Cognitive Level: Analysis REF: 633 OBJ: 6 TOP: Gastroenteritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: The ESR elevates in the presence of an inflammatory response. 2. The nurse explains that because drinks cause diuresis, they are not good choices for fluid replacement in a child who is dehydrated. ANS: cola caffeinated DIF: Cognitive Level: Application REF: 643 OBJ: 6 TOP: Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort NOT: Rationale: Cola drinks or other caffeinated drinks cause diuresis and will further dehydrate an already dehydrated child. 3. The nurse explains that rickets, a deficiency disease that causes bony deformities, is caused by the inadequate supply of vitamin . ANS: D DIF: Cognitive Level: Knowledge REF: 651 OBJ: N/A TOP: Rickets KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: Rickets is caused by a deficiency of vitamin D. 4. The nurse reminds parents of a child allergic to cows milk that they should avoid foods that list as part of their contents. ANS: casein Chapter 16. Renal disorders MULTIPLE CHOICE 1. The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection in the child. The statement made by the parent indicating a need for further teaching is: a. My daughter should wash and wipe the perineal area from front to back. b. I am only going to have my daughter wear cotton underwear. c. It is acceptable to take frequent bubble baths. d. She needs to drink lots of fluids and void frequently. ANS: C Oils in bubble bath and similar products are known to irritate the urethra. DIF: Cognitive Level: Application REF: dm: 666, NCP 28-1 OBJ: Objective: N/A TOP: Topic: Acute Urinary Tract Infection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 2. When asked about correcting the hypospadias of their newborn, the nurse explains that with this condition: a. No intervention is necessary as the defect will correct itself over time. b. Surgical repair of the hypospadias is done before 18 months of age. c. Corrective surgery is usually delayed until the preschool period. d. Repairing the defect will increase the risk of testicular cancer. ANS: B Treatment of hypospadias consists of surgical repair and is usually performed before 18 months of age. DIF: Cognitive Level: Comprehension REF: dm: 662 OBJ: Objective: 8 TOP: Topic: Hypospadias KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The initial sign of nephrosis that the nurse might note in the child would be: a.asRpberry-like rash b. Periorbital edema c. Temperature elevation d. Abdominal pain ANS: B The edema of nephrotic syndrome is generalized, and not readily noticed, even by the parents, but an early sign that can be assessed is periorbital edema. DIF: Cognitive Level: Application REF: dm: 662 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 4. While a child is receiving prednisone to treat nephrotic syndrome, it is important for the nurse to assess the child for: a. Infection b. Urinary retention c. Easy bruising d. Hypoglycemia ANS: A Prednisone depresses the immune response and increases susceptibility to infection. Because steroids mask signs of infection, the child must be assessed for more subtle symptoms of illness. DIF: Cognitive Level: Analysis REF: dm: 663 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. During a physical assessment of a hospitalized 5-year-old, the nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. The nurse should: a. Forcibly push the foreskin down over the head of the penis. b. Place a warm compress on the penis. c. Notify the charge nurse. d. Wait a few hours and try again. ANS: C Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the penis; this should be remedied immediately. DIF: Cognitive Level: Application REF: dm: 662 OBJ: Objective: 1 TOP: Topic: Paraphimosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. An appropriate nursing intervention for this child would be: a. Providing activities for the child on restricted activity b. Feeding the child a protein-restricted diet c. Carefully handling edematous extremities d. Observing the child for evidence of hypotension ANS: A Although children may feel well, activity is limited until hematuria resolves. DIF: Cognitive Level: Application REF: dm: 669 OBJ: Objective: 2 TOP: Topic: Acute Glomerulonephritis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 7. The nurse clarifies that the urinary diversion procedure that would be least damaging to the body image of the adolescent would be: a. Urostomy b. Ileal conduit c. Nephrostomy d. Suprapubic placement ANS: B The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no external appliance as is needed with the other diversion methods. DIF: Cognitive Level: Analysis REF: dm: 664, Table 28-2 OBJ: Objective: 8 TOP: Topic: Obstructive Uropathy-Urinary Diversions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he needs to get immunizations to enter kindergarten. The nurse clarifies that while on prednisone, immunizations: a. Can interfere with the treatment for nephrosis b. Require that the child have antibiotic coverage c. Can be given in smaller, divided doses d. Should be delayed ANS: D No vaccinations or immunizations should be administered while the disease is active and during immunosuppressive therapy. DIF: Cognitive Level: Comprehension REF: dm: 668 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 9. When diuresis has not occurred after a month on corticosteroids, the nurse explains to the parents of a child with nephrotic syndrome that diuresis can be brought about by a protocol of: a. Ibuprofen, an antiinflammatory agent b. Lasix, a diuretic c. Cipro, an antibiotic d. Cytoxan, an antisuppressant ANS: D A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have proven ineffective. DIF: Cognitive Level: Analysis REF: dm: 667 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. Because of the hyperkalemia associated with acute glomerulonephritis, the nurse recommends that the child avoid such foods as: a. Dairy products b. Whole-grain cereals c. Organ meats d. Bananas ANS: D Bananas are very high in potassium and should be avoided. DIF: Cognitive Level: Application REF: dm: 669 OBJ: Objective: 2 TOP: Topic: AGN KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. The physical assessment that the nurse would omit in caring for a 2-year-old who has a Wilms tumor is: a. Performing ROM on lower extremities b. Palpating the abdomen c. Assessing for bowel sounds d. Percussing ankle and knee reflexes ANS: B Palpation of the abdomen could disturb the tumor and cause spread of the malignancy. DIF: Cognitive Level: Application REF: dm: 669 OBJ: Objective: 7 TOP: Topic: Wilms Tumor KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. Parents are speaking with the urologist about their sons undescended testicle. The nurse determines the childs father understands the information presented when he states: a. An undescended testicle can reduce fertility. b. The testicle usually descends spontaneously during the first month of life. c. Surgical correction reduces the risk for testicular tumors. d. The optimal time to surgically correct the condition is at diagnosis. ANS: A Although orchiopexy improves the condition, the fertility rate among patients may be reduced even when only one testis is undescended. DIF: Cognitive Level: Analysis REF: dm: 672 OBJ: Objective: 9 TOP: Topic: Cryptorchidism KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A parent tells the nurse her child is scheduled for an x-ray of the bladder and urethra that is done while the child is urinating. The nurse recognizes this description as a(n): a. Cystometrogram b. Cystoscopy c. Voiding cystourethrogram d. Intravenous pyelogram ANS: C An x-ray examination of the bladder and urethra before and during micturition is called a voiding cystourethrogram. DIF: Cognitive Level: Comprehension REF: dm: 661 OBJ: Objective: 4 TOP: Topic: Diagnostic Procedures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. A 6-year-old child with daytime enuresis complains of dysuria and urgency; the nurse recognizes these as signs and symptoms of: a. Urinary tract infection b. Nephrotic syndrome c. Acute glomerulonephritis d. Vesicoureteral reflux ANS: A Urinary frequency and pain during micturition are symptoms of acute urinary tract infection. DIF: Cognitive Level: Analysis REF: dm: 665 OBJ: Objective: N/A TOP: Topic: Acute Urinary Tract Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 15. An appropriate intervention for the child with minimal change nephrotic syndrome who is edematous would be to: a. Teach the child to minimize body movements. b. Change the childs position frequently. c. Keep the head of the childs bed flat. d. Keep edematous areas moist and covered. ANS: A The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate skin. DIF: Cognitive Level: Analysis REF: dm: 667 OBJ: Objective: 5 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. The statement made by a parent of a child with nephrotic syndrome indicating an understanding of discharge teaching is: a. I will make sure he gets his measles vaccine as soon as he gets home. b. He can stop taking his medication next week. c. I should check his urine for protein when he goes to the bathroom. d. He should eat a low-protein diet for the next few weeks. ANS: C The parents should be instructed to keep a daily record of the childs urinary proteins. DIF: Cognitive Level: Analysis REF: dm: 667 OBJ: Objective: N/A TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the childs history, the nurse recognizes the probable cause of this condition as: a. Recovered from German measles 2 months ago b. Dysuria since the previous night c. A history of allergy d. A sore throat 2 weeks ago ANS: D Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which causes an allergic-type response that alters the effectiveness of the glomeruli. DIF: Cognitive Level: Analysis REF: dm: 668 OBJ: Objective: 2 TOP: Topic: Acute Glomerulonephritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection. The nurse determines the adolescent understands the information when she says a good drink to keep urine acidic is: a. Milk b. Grape juice c. Apple juice d. Orange juice ANS: C Juices such as apple or cranberry help maintain acidity of urine. DIF: Cognitive Level: Analysis REF: dm: 666, NCP 28-1 OBJ: Objective: N/A TOP: Topic: Acute Urinary Tract Infection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 19. The 6-year-old scheduled for an orchiopexy shyly asks the nurse, What are they going to do to me down there? The nurses best response would be: a. They are going to fix you up down there b. They will move your testicle from your abdomen to your scrotum. c. What do you think your doctor is going to do? d. You shouldnt worry. Your doctor knows exactly what to do. ANS: C Encourage the patient to talk about what he knows and what feelings he has about the surgery. School-age children have a fear of bodily harm. DIF: Cognitive Level: Analysis REF: dm: 672 OBJ: Objective: 8 TOP: Topic: Orchipexy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation MULTIPLE RESPONSE 1. The nurse caring for a newborn with exstrophy of the bladder will include in the care: Select all that apply. a. Diaper infant tightly. b. Protect skin around bladder. c. Position infant on back. d. Prepare for surgical closure. e. Cover exposed bladder with shield. ANS: B, C, D, E The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is constantly bathed with urine. These infants are diapered loosely, if at all. Surgical closure is done as quickly as possible. DIF: Cognitive Level: Analysis REF: dm: 663 OBJ: Objective: N/A TOP: Topic: Exstrophy of the Bladder KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse caring for a child with nephrotic syndrome is alert to the classic symptoms of this disorder, which are: Select all that apply. a. Proteinuria b. Grossly bloody urine c. Hyperalbuminemia d. Fatigue e. Generalized edema ANS: A, B, D, E All options listed are those of nephrotic syndrome with the exception of hyperalbuminemia. The nephrotic child has hypoalbuminemia, as most of the protein has been spilled in the urine. DIF: Cognitive Level: Analysis REF: dm: 665-666 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection COMPLETION 1. The nurse explains that the test that measures the pressure and volume of the urine stream is called the . ANS: uroflowmeter DIF: Cognitive Level: Knowledge REF: dm: 661 OBJ: Objective: 4 TOP: Topic: Uroflowmeter KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection NOT: Rationale: The test that specifically measures the dynamics of micturition is the uroflowmeter 2. The nurse uses a diagram to show how the , the working unit of the kidney, filters and regulates fluids. ANS: nephron DIF: Cognitive Level: Comprehension REF: dm: 664 OBJ: Objective: 3 TOP: Topic: Nephron KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: The nephron is the working unit of the kidney that filters and regulates fluids in the body. There are roughly 1 million nephrons in each kidney. 3. When a childs ureter becomes completely obstructed from scarring, the nurse explains that urinary diversion may be necessary to prevent the reflux back into the renal pelvis from causing . ANS: hydronephrosis Chapter 17. Endocrine disorders MULTIPLE CHOICE 1. The nurse planning to teach a family about Tay-Sachs disease understands the pattern of inheritance for inborn errors of metabolism is usually: a. Autosomal recessive b. Autosomal dominant c. X-linked recessive d. Multifactorial ANS: A The pattern of inheritance is generally autosomal recessive. DIF: Cognitive Level: Knowledge REF: dm: 696 OBJ: Objective: N/A TOP: Topic: Inborn Errors of Metabolism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 2. The nurse explains that because of an inadequate secretion of insulin: a. Protein synthesis is increased. b. Increased fat breakdown leads to ketonemia. c. Serum glucose levels are markedly decreased. d. More rapid conversion and storage of carbohydrates to glucose occurs. ANS: B When insulin is deficient, the body cannot metabolize carbohydrates for energy. The body is also unable to store and use fat properly. Incomplete fat metabolism produces ketone bodies that accumulate in the blood. DIF: Cognitive Level: Comprehension REF: dm: 698 OBJ: Objective: 4 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse caring for a child with a new diagnosis of type 1 diabetes mellitus plans the care based on the understanding that: a. There is an absolute deficiency of insulin. b. Insufficient quantities of insulin are produced by the pancreas. c. Oral hypoglycemic agents can control it. d. Insulin deficiency is caused by another disease affecting the pancreas. ANS: A Type 1 insulin-dependent diabetes mellitus is characterized by an absolute or complete deficiency of insulin. DIF: Cognitive Level: Comprehension REF: dm: 699 OBJ: Objective: 4 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A child receives a combination of regular and NPH insulin at 8:00 AM. At 8:45 AM, when the breakfast trays have not yet arrived from the kitchen, the nurse should: a. Notify the charge nurse. b. Give the patient a snack of graham crackers and milk. c. Ambulate the patient in the hall for a short time. d. Give the patient more insulin according to the sliding scale. ANS: B A child who receives regular insulin before meals may have an insulin reaction if food is not eaten within 20 minutes. A snack of graham crackers and milk will prevent an episode of hypoglycemia. DIF: Cognitive Level: Application REF: dm: 701, Table 30-4 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 5. Although the type 1 diabetic child had her prescribed insulin at 7:30 AM, the child is complaining of hunger and thirst and is drowsy at noon. The nurse should: a. Administer glucagon immediately and test her blood with a glucometer in 10 minutes. b. Have her eat some peanut butter crackers. c. Give her a cup of orange juice. d. Test her blood with a glucometer and give insulin according to the sliding scale. ANS: D The immediate treatment for hyperglycemia is to give the patient more insulin. Giving more sugar will increase the blood sugar in a hyperglycemic child. Walking exercise will use up even more glucose. DIF: Cognitive Level: Application REF: dm: 707 OBJ: Objective: 3 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. The comment made by a school-age child, indicating that he needs more teaching about diabetes mellitus and exercise, is: a. I carry a piece of hard candy with me in case I start to feel shaky. b. I make sure I have emergency money when I have soccer practice or a game. c. Sometimes I skip my breakfast when I have a game in the morning. d. I play in soccer games that are scheduled after dinner. ANS: C Blood sugar is high after meals. The child with type 1 diabetes mellitus who skips a meal before exercise is at risk for hypoglycemia. DIF: Cognitive Level: Analysis REF: dm: 703 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The statement made by a 7-year-old child with diabetes mellitus that indicates a need for more teaching is: a. My pancreas is sick and needs insulin until it gets better. b. I will need to take my insulin every day. c. I need to keep a piece of candy in my pocket in case I start to feel shaky. d. My mom has to give me insulin shots twice a day. ANS: A The child with type 1 diabetes mellitus has a complete insulin deficiency and will require lifelong management of this disease. Insulin does not cure the pancreas. DIF: Cognitive Level: Analysis REF: dm: 699 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. The general dietary measure the nurse will include in a teaching plan for the child with type 1 diabetes mellitus is: a. Control intake of carbohydrates and consume fewer calories. b. Restrict concentrated carbohydrates and eat foods high in fiber. c. Calories must come from proteins and fats. d. Eat a diet low in fat and low in complex carbohydrates. ANS: B The nutritional needs of a child with diabetes mellitus are essentially the same as those of the nondiabetic child, with the exception of the elimination of concentrated carbohydrates such as sugar. Fiber has been shown to reduce blood sugar levels. DIF: Cognitive Level: Comprehension REF: dm: 704 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A child with diabetes is brought to the emergency department; he is flushed, his skin is dry, and he is drowsy. His father states that the child has been feeling progressively worse since the morning. This child is most likely experiencing: a. Somogyi syndrome b. Insulin shock c. Ketoacidosis d. Water intoxication ANS: C In ketoacidosis the childs skin is dry and the face is flushed. Patients appear dehydrated. They may perspire and be restless. The breath has a fruity odor, and there is no rest period between inspiration and expiration. DIF: Cognitive Level: Analysis REF: dm: 701 OBJ: Objective: 3 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A mother reports that her 4-month-old infant is lethargic, is sleeping 18 hours a day, and is snoring. The nurse recognizes that these signs are characteristic of: a. Hypothyroidism b. Hyperthyroidism c. Type 1 diabetes mellitus d. Tay-Sachs disease ANS: A The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing noisy respiration. DIF: Cognitive Level: Analysis REF: dm: 679 OBJ: Objective: 12 TOP: Topic: Hypothyroidism KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 11. An important consideration for the school-age child taking DDAVP for diabetes insipidus would be: a. Observing for signs of water deprivation b. Restricting his physical education program c. Permitting the child to use the bathroom when needed d. Limiting fluid intake other than during the lunch period ANS: C The child with diabetes insipidus needs liberal access to bathrooms and water fountains. DIF: Cognitive Level: Application REF: dm: 698 OBJ: Objective: 13 TOP: Topic: Diabetes Insipidus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. The laboratory data indicating good metabolic control for a child with type 1 diabetes mellitus are: a. Glycosylated hemoglobin value of 8% b. Fasting blood glucose level less than 140 mg/dl c. Glucose tolerance test result of 190 mg/dl d. No glucose or ketones present in the urine ANS: A Glycosylated hemoglobin reflects glycemic levels over a period of months. Levels of 6% to 9% represent good metabolic control. DIF: Cognitive Level: Analysis REF: dm: 701 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The condition the nurse suspects when a child with type 1 diabetes mellitus has hyperglycemia, diaphoresis, and headaches in the morning is: a. Dawn phenomenon b. Somogyi phenomenon c. Honeymoon effect d. Ketoacidosis ANS: B The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level is lowered to the point at which the bodys counter-regulatory hormones are released, producing the symptoms described. DIF: Cognitive Level: Analysis REF: dm: 708 OBJ: Objective: 9 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. What would be the most appropriate nursing response to a woman who says, My sister had a child with Tay-Sachs disease. I want to know if I could have a child with this condition. a. The disease is rare. It is unlikely that you would have a child with Tay-Sachs disease. b. A screening test can be done to determine if you are a carrier of the gene. c. The gene for Tay-Sachs disease is transmitted by the father. d. The cause of Tay-Sachs disease is thought to be an autoimmune response to a virus. ANS: B Carriers can be identified by screening tests. Tay-Sachs disease has an autosomal recessive pattern of transmission. DIF: Cognitive Level: Analysis REF: dm: 696 OBJ: Objective: N/A TOP: Topic: Tay-Sachs Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 15. The nurse determines a parent is administering Synthroid correctly when she states: a. I stopped giving the medication because my daughter was losing her hair. b. I am using a different brand now because it costs less money. c. I dont give the medication on the weekends. d. I give the medication at 8:00 AM everyday. ANS: D Synthroid should be given at the same time each day, preferably in the morning. DIF: Cognitive Level: Analysis REF: dm: 725 OBJ: Objective: N/A TOP: Topic: Hypothyroidism KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. Following a closed head injury, the unconscious 10-year-old child begins to excrete copious amounts of pale urine with an attendant drop in blood pressure. Based on these symptoms, the nurse suspects the development of: a. Diabetes insipidus b. Diabetes mellitus c. Hypothyroidism d. Hyperthyroidism ANS: A Diabetes insipidus can be acquired as the result of a head injury or tumor, and suppression of the posterior pituitary causes copious urine output with an attendant drop in BP. The child can become dehydrated very quickly if some remedy is not applied. DIF: Cognitive Level: Application REF: dm: 697 OBJ: Objective: N/A TOP: Topic: Diabetes Insipidus KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 17. The nurse teaching parents of a child with diabetes insipidus about water intoxication would tell the parents to be alert for: a. Polyuria b. Cough c. Weight loss d. Lethargy ANS: D Signs of water intoxication include edema, lethargy, nausea, and CNS signs. DIF: Cognitive Level: Comprehension REF: dm: 698 OBJ: Objective: N/A TOP: Topic: Diabetes Insipidus KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 18. The parents of a child newly diagnosed with diabetes mellitus tell the nurse, Our sons body is resistant to insulin. The nurse recognizes this description as consistent with: a. Type 1, insulin-dependent diabetes mellitus b. Type 2, noninsulin-dependent diabetes mellitus c. Maturity-onset diabetes of youth d. Drug-induced diabetes ANS: B Type 2, noninsulin-dependent, diabetes mellitus is caused by insulin resistance or failure of the body to use the insulin. DIF: Cognitive Level: Comprehension REF: dm: 699 OBJ: Objective: 4 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. When teaching a 12-year-old how to administer insulin, the nurse includes the following instruction: a. Make sure injection sites are 6 inches apart. b. Select an injection site that was recently exercised. c. Inject the needle at a 90-degree angle. d. The injection is given deep into the muscle. ANS: C It is easier for the child to learn to inject the needle at a 90-degree angle. DIF: Cognitive Level: Application REF: dm: 708 OBJ: Objective: 10 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 20. The nurse discussed treatment of hypoglycemia with an adolescent. The nurse determined the adolescent understood the instructions when she verbalized that if her blood sugar is low or if she begins to feel hungry and weak, she will: a. Eat six LifeSavers b. Give herself Lispro insulin c. Have a slice of cheese d. Drink a diet soda ANS: A The immediate treatment of hypoglycemia consists of administering sugar in some form such as orange juice, hard candy, or a commercial product. DIF: Cognitive Level: Analysis REF: dm: 701 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection MULTIPLE RESPONSE 1. The nurse explains that the endocrine system is primarily responsible for controlling the processes of: Select all that apply. a. Maturation b. Reproduction c. Sexual identity d. Stress response e. Growth ANS: A, B, D, E The endocrine system governs maturation, reproduction, stress response, and sexual maturity. Sexual identity is a psychosocial response. DIF: Cognitive Level: Comprehension REF: dm: 695 OBJ: Objective: N/A TOP: Topic: Endocrine System KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The home health nurse monitoring an 8-month-old hypothyroid child taking Synthroid, recognizes signs of overdose when the assessment reveals: Select all that apply. a. Tachycardia b. Irritability c. Vomiting d. Weight loss e. Diaphoresis ANS: A, B, D, E All the options with the exception of vomiting are indications of overdose of Synthroid. DIF: Cognitive Level: Analysis REF: dm: 697 OBJ: Objective: 12 TOP: Topic: Hypothyroidism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 3. The nurse warns that keeping diabetes in control in an adolescent is made difficult because of: Select all that apply. a. Hormonal changes b. Developmental conflict of independence vs. dependence c. Addiction to fast food d. Growth spurt e. Denial of disease ANS: A, B, C, D, E The adolescent who is in a growth spurt and filled with raging hormones resents and denies the need to be dependent on a medication. Medication schedules and diet restrictions do not correlate well with the adolescents lifestyle of eating fast foods. DIF: Cognitive Level: Application REF: dm: 701 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 1. The nurse explains that the diagnosis of diabetes is made when the fasting blood glucose level is mg/dl on two separate occasions, and the history is positive for indication of the disease. ANS: 126 DIF: Cognitive Level: Application REF: dm: 700 OBJ: Objective: 6 TOP: Topic: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: An elevated blood glucose level of 126 mg/dl on two separate occasions is grounds for the diagnosis of DM when the history is positive for the disease. 2. The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can evaluate average glucose levels over a period of to months. ANS: 3, 4 Chapter 18. Reproductive and Genetic Disorders MULTIPLE CHOICE 1. Obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid may be responsible for the occurrence of: a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus ANS: D Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain. DIF: Cognitive Level: Knowledge REF: dm: 320 OBJ: Objective: 4 TOP: Topic: Hydrocephalus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse caring for an infant with hydrocephalus would take special precaution to: a. Align the limbs b. Support the head c. Keep the head lower than the hips d. Check intake and output ANS: B The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the child to prevent injury to the neck. DIF: Cognitive Level: Comprehension REF: dm: 321 OBJ: Objective: 4 TOP: Topic: Hydrocephalus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. The nurse positions this infant: a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In the semi-Fowlers position ANS: D If the fontanels are bulging, the child would be positioned in a semi-Fowlers position to promote drainage from the ventricles through the shunt. DIF: Cognitive Level: Application REF: dm: 322 OBJ: Objective: 4 TOP: Topic: Hydrocephalus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. After feeding a baby with hydrocephalus, the nurse will take special care to: a. Sit the baby upright in an infant seat b. Place the baby over the shoulder to burp c. Leave the baby in a side-lying position d. Stimulate the baby by rubbing its feet ANS: C Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-lying position in a quiet atmosphere to reduce the incidence of vomiting. DIF: Cognitive Level: Application REF: dm: 322 OBJ: Objective: 4 TOP: Topic: Feeding a Hydrocephalic Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A newborn was just admitted to the NICU with a meningomyelocele. The priority for preoperative nursing care of this newborn is to protect the sac by: a. Keeping the sac dry b. Diapering snugly c. Positioning prone in an incubator d. Moving from side to side every hour ANS: C The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The babys hips are kept lower than the lesion, and the baby is usually not in diapers. DIF: Cognitive Level: Analysis REF: dm: 324 OBJ: Objective: 6 TOP: Topic: Myelodysplasia and Spina Bifida KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse caring for the child who has had a ventriculoperitoneal shunt for hydrocephalus observes an increasing abdominal girth. The most appropriate response would be to: a. Elevate the childs head b. Check bowel sounds c. Record retention of feeding d. Notify charge nurse of possible malabsorption ANS: D An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the CSF that is being shunted to the peritoneum. DIF: Cognitive Level: Application REF: dm: 322 OBJ: Objective: 5 TOP: Topic: V-P Shunt KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. The nurse counsels the parents of a child with a cleft palate that they should be alert for signs of: a. Facial paralysis b. Ear infections c. Increasing ICP d. Drooling ANS: B Children with cleft palate are at risk of ear infections and dental disorders. DIF: Cognitive Level: Application REF: dm: 328 OBJ: Objective: 2 TOP: Topic: Complication of Cleft Palate KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. Postoperative nursing care of the infant following surgical repair of a cleft lip would include: a. Feeding the infant with a spoon to avoid sucking b. Positioning the infant on the abdomen to facilitate drainage c. Applying elbow restraints to protect the surgical area d. Providing minimal stimulation to prevent injury to the incision ANS: C Elbow restraints are used postoperatively to prevent the infant from damaging the operative area. DIF: Cognitive Level: Application REF: dm: 326 OBJ: Objective: 9 TOP: Topic: Cleft Lip and Palate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. The statement that indicates parents understand how to feed their infant who had surgical repair of a cleft lip is: a. We are feeding the baby with a dropper for two weeks. b. We resumed bottle feeding after discharge. c. We started the baby on solid food yesterday. d. The baby is drinking well from a straw. ANS: A The infant is fed with a dropper until the incision is completely healed, about 1 to 2 weeks after surgery. DIF: Cognitive Level: Application REF: dm: 327 OBJ: Objective: 9 TOP: Topic: Cleft Lip and Palate KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. An 18-month-old child who has had a surgical repair of a cleft palate is now allowed to eat a regular diet. The adjustment the nurse would make in feeding is: a. Feed solid foods with the spoon at the side of the mouth. b. Puree foods and offer them through a straw. c. Place small bites of food in the mouth with a tongue blade. d. Offer small, frequent meals of finger foods. ANS: A The primary concern with feeding is to protect the operative site. The child can be fed with a spoon, but only the side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of the mouth. DIF: Cognitive Level: Application REF: dm: 327 OBJ: Objective: 9 TOP: Topic: Cleft Lip and Palate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. The nurse bathing an infant would recognize a sign of developmental hip dysplasia, which is: a. Hypotonicity of the leg muscles b. One leg is shorter than the other c. Broadening and flattening of the buttocks d. Two skin folds on the back of each thigh ANS: B When developmental hip dysplasia is present, the leg on the affected side will appear shorter than the leg on the unaffected side. DIF: Cognitive Level: Application REF: dm: 329 OBJ: Objective: 10 TOP: Topic: Developmental Hip Dysplasia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse explains that the usual treatment for this infant would be: a.PaAvli k harness b. A body spica cast c. Traction d. Triple-diapering ANS: A In infants more than 2 months of age, longer-term immobilization with a Pavlik harness is required. DIF: Cognitive Level: Comprehension REF: dm: 330 OBJ: Objective: 10 TOP: Topic: Developmental Hip Dysplasia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Following delivery, a mother asks the nurse about newborn screening tests. The nurse explains that the optimal time for testing for phenylketonuria is: a. In the first 24 hours of life b. After 2 to 3 days c. At 4 to 6 weeks of age d. At 2 months of age ANS: B Blood tests for phenylketonuria should be obtained 48 to 72 hours after birth. The newborn will have had enough time to ingest protein through feedings and the chance of false-negative results will be reduced. DIF: Cognitive Level: Application REF: dm: 332 OBJ: Objective: 7 TOP: Topic: Metabolic Defects KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse advising parents about feeding their infant who has phenylketonuria, would include the information to: a. Provide a life-long high-protein diet. b. Use a formula that is low in the amino acid leucine. c. Feed the baby a soy-based formula. d. Substitute Lofenalac for some protein foods. ANS: D A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted for natural protein foods. DIF: Cognitive Level: Application REF: dm: 333 OBJ: Objective: 7 TOP: Topic: Metabolic Defects KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. Parents of a 2-month-old Down syndrome infant should be instructed, because of the generalized hypotonicity of the child, that special attention should be given to: a. Careful feeding b. Respiratory care c. Range of motion d. Incontinent care ANS: B The child with Down syndrome has generalized hypotonicity, which caused mucus accumulation and respiratory problems DIF: Cognitive Level: Application REF: dm: 334 OBJ: Objective: 11 TOP: Topic: Down Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. The nurse instructing parents about positioning their toddler who has just had a body spica cast applied would include to: a. Prop the child upright with pillows for meals. b. Use the bar between the legs to turn the child. c. Put the child on her abdomen to sleep. d. Change the childs position frequently. ANS: D The childs position must be changed frequently to relieve pressure on body points and promote circulation. DIF: Cognitive Level: Application REF: dm: 332 OBJ: Objective: 10 TOP: Topic: Developmental Hip Dysplasia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse explains that the Rh-negative mother who should receive RhoGAM is the mother who: a. Has had one Rh-negative child and is pregnant with an Rh-negative child b. Had an Rh-positive baby and is pregnant with an Rh-positive baby c. Has had an O-negative child and is pregnant with a B-negative child d. Is a primipara with an O-negative child ANS: B The only woman with antibodies against the Rh-positive baby is the Rh-negative woman who has had one Rh-positive child and is now pregnant with another. DIF: Cognitive Level: Analysis REF: dm: 337 OBJ: Objective: 12 TOP: Topic: Rh Concerns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. When the parents ask what the light does for their jaundiced baby, the nurse responds that the light: a. Increases the babys metabolism b. Stimulates liver function c. Dilates blood vessels d. Breaks down bilirubin ANS: D Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted. DIF: Cognitive Level: Application REF: dm: 338 OBJ: Objective: 12 TOP: Topic: Hemolytic Disease of the Newborn KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair: a. Immediately after birth b. By 3 months of age c. After 12 months of age d. Varies in every case ANS: B A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection. DIF: Cognitive Level: Application REF: dm: 327 OBJ: Objective: 9 TOP: Topic: Cleft Lip KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. Phototherapy is instituted for an infant with jaundice. An appropriate nursing action for the infant with jaundice is to: a. Cover the infants head with a hat. b. Dress the infant lightly in a T-shirt. c. Keep the infants eyes covered. d. Reposition at least every 4 to 8 hours. ANS: C The infants eyes are protected with patches to prevent damage from the high-intensity lights. DIF: Cognitive Level: Application REF: dm: 338 OBJ: Objective: 12 TOP: Topic: Hemolytic Disease of the Newborn KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse is caring for a newborn whose mother has diabetes. The nurse would assess the neonate for: a. Hypoglycemia b. Erythroblastosis fetalis c. Intracranial hemorrhage d. Pancreatic failure ANS: A The newborn of a mother with diabetes is prone to hypoglycemia. DIF: Cognitive Level: Analysis REF: dm: 343 OBJ: Objective: N/A TOP: Topic: Infant of a Diabetic Mother KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE 1. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crack-addicted mother, which would be manifested by: Select all that apply. a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite ANS: A, B, C The neonate with abstinence syndrome will be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite. DIF: Cognitive Level: Application REF: dm: 242-243 OBJ: Objective: 2 TOP: Topic: Neonatal Abstinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. The nurse assesses the hydrocephalic child for increasing ICP, which would be manifested by: Select all that apply. a. High-pitched cry b. Inequality of pupils c. Bulging fontanelles d. Diarrhea e. Strabismus ANS: A, B, C Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles. DIF: Cognitive Level: Application REF: dm: 322 OBJ: Objective: 4 TOP: Topic: Signs of ICP KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk COMPLETION 1. The nurse uses a diagram to show that when the CSF is obstructed in the subarachnoid space rather than in the ventricles, the resulting hydrocephalus is diagnosed as hydrocephalus. ANS: communicating DIF: Cognitive Level: Comprehension REF: dm: 321 OBJ: Objective: 2 TOP: Topic: Communicating Hydrocephalus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: Communicating hydrocephalus occurs when the CFS is obstructed in the subarachnoid space rather than in the ventricles. 2. The nurse clarifies to the parents of a child with spina bifida that their child has a portion of the spinal cord in the sac, in addition to the meninges, which makes this defect a . ANS: meningomyelocele DIF: Cognitive Level: Application REF: dm: 223 OBJ: Objective: 2 TOP: Topic: Meningomyelocele KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: A spina bifida that includes a portion of the cord in the sac in addition to the meninges is classified as a meningomyelocele. 3. The nurse demonstrates how to flush the ventriculoperitoneal shunt by the use of the that is in place behind the babys ear. ANS: pump Chapter 19. Hematologic, Immunologic, and Neoplastic Disorders MULTIPLE CHOICE 1. When teaching the mother of a young child about iron deficiency anemia, the nurse would tell her that a rich source of iron is: a. Egg whites b. Cream of wheat c. Bananas d. Carrots ANS: B Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, cream of wheat, dried fruits, beans, nuts, and whole-grain breads. DIF: Cognitive Level: Application REF: dm: 612 OBJ: Objective: 7 TOP: Topic: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The statement by a mother that may indicate a cause for her 9-month-old having iron deficiency anemia is: a. Formula is so expensive. We switched to regular milk right away. b. She almost never drinks water. c. She doesnt really like peaches or pears, so we stick to bananas for fruit. d. I give her a piece of bread now and then. She likes to chew on it. ANS: A Because cows milk contains very little iron, infants should drink iron-fortified formula for the first year of life. DIF: Cognitive Level: Analysis REF: dm: 612 OBJ: Objective: 6 TOP: Topic: Iron Deficiency Anemia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse would instruct the parent to give ferrous sulfate drops to the child: a. With milk b. With orange juice c. With water d. On a full stomach ANS: B Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron. DIF: Cognitive Level: Application REF: dm: 613 OBJ: Objective: 6 TOP: Topic: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. The nurse would ask the patient with hemophilia A to reconsider a vacation he has planned to: a. The Caribbean for a cruise b. Denver for skiing c. Canada for a rail tour d. New England for a bus tour ANS: B Hemophiliacs are discouraged from exercising in high altitudes and exposure to cold as this depletes their already low oxygen concentration. DIF: Cognitive Level: Analysis REF: dm: 616 OBJ: Objective: 14 TOP: Topic: Hemophilia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 5. A 2-year-old child has been diagnosed with hemophilia A. The information the nurse would include in a teaching plan about home care would be: a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b. Childrens aspirin in lowered doses may be given for joint discomfort. c. A firm, dry toothbrush should be used to clean teeth at least twice a day. d. Do not permit interactive play with other children. ANS: A When bleeding occurs, the traditional approach is to follow RICErest, ice, compression, and elevation. DIF: Cognitive Level: Application REF: dm: 618 OBJ: Objective: 15 TOP: Topic: Hemophilia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse would teach the parents of a child with a low platelet count to avoid: a. Ibuprofen b. Aspirin c. Caffeine d. Prednisone ANS: B Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding. DIF: Cognitive Level: Application REF: dm: 619 OBJ: Objective: 17 TOP: Topic: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. A child who is receiving a transfusion should be closely assessed for: a. Fever b. Lethargy c. Jaundice d. Bradycardia ANS: A The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain. DIF: Cognitive Level: Analysis REF: dm: 622 OBJ: Objective: 13 TOP: Topic: Blood Transfusion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 8. On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. The priority nursing intervention is: a. Assessing neurological status b. Inserting an intravenous line c. Monitoring vital signs during platelet transfusions d. Providing family education about how to prevent bleeding ANS: A When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are therefore a priority of care. DIF: Cognitive Level: Analysis REF: dm: 619 OBJ: Objective: 17 TOP: Topic: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. The disease is in: a. Stage I b. Stage II c. Stage III d. Stage IV ANS: C Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage III Hodgkins disease. DIF: Cognitive Level: Analysis REF: dm: 623, Table 26-2 OBJ: Objective: N/A TOP: Topic: Hodgkins Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis for severe abdominal pain. The nurse recognizes that the type of crisis the child is most likely experiencing is: a. Aplastic b. Hyperhemolytic c. Vaso-occlusive d. Splenic sequestration ANS: C Vaso-occlusive crises or painful crises are caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm. DIF: Cognitive Level: Analysis REF: dm: 615, Table 26-1 OBJ: Objective: 12 TOP: Topic: Sickle Cell Anemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The statement made by a parent indicating understanding of health maintenance of a child with sickle cell anemia is: a. I should give my child a daily iron supplement. b. It is important for my child to drink plenty of fluids. c. He needs to wear protective equipment if he plays contact sports. d. He shouldnt receive any immunizations until he is older. ANS: B Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with sickle cell disease. DIF: Cognitive Level: Analysis REF: dm: 616 OBJ: Objective: 10 TOP: Topic: Sickle Cell Anemia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait. How can the nurse best explain their childrens risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b. All of their children will be carriers, just as they are. c. Each child has a one-in-four chance of having the disease and a two-in-four chance of being a carrier. d. The risk levels of their children cannot be determined by this information. ANS: C The sickle cell gene is inherited from both parents; therefore each offspring has a one-in-four chance of inheriting the disease. DIF: Cognitive Level: Analysis REF: dm: 614, Figure 26-4 OBJ: Objective: 11 TOP: Topic: Sickle Cell Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. A child with thalassemia major receives blood transfusions frequently. The nurse is aware that a complication of repeated blood transfusions is: a. Hemarthrosis b. Hematuria c. Hemoptysis d. Hemosiderosis ANS: D As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues. DIF: Cognitive Level: Analysis REF: dm: 617 OBJ: Objective: 13 TOP: Topic: Thalassemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A child has just been diagnosed with acute lymphoblastic leukemia. The nurse is aware that the result of an overproduction of immature white blood cells in the bone marrow is: a. Decreased T-cell production b. Decreased hemoglobin c. Increased blood clotting d. Increased susceptibility to infection ANS: D An overproduction of immature white blood cells increases the childs susceptibility to infection. DIF: Cognitive Level: Comprehension REF: dm: 620 OBJ: Objective: 17 TOP: Topic: Leukemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. When the child receiving a transfusion complains of back pain and itching, the nurses initial action would be to: a. Notify the charge nurse b. Disconnect IV lines immediately c. Give Benadryl d. Clamp off blood and keep line open with NS ANS: D If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse. DIF: Cognitive Level: Application REF: dm: 622 OBJ: Objective: 18 TOP: Topic: Blood Transfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse would include in a teaching plan about mouth care of a child receiving chemotherapy to: a. Use commercial mouthwash b. Clean teeth with a soft toothbrush c. Avoid use of a Waterpik d. Inspect the mouth weekly for ulcerations ANS: B A soft toothbrush reduces capillary damage and mucous membrane breakdown, and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection. Waterpiks are useful for toughening gums. DIF: Cognitive Level: Application REF: dm: 622 OBJ: Objective: 17 TOP: Topic: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. A 6-year-old with leukemia asks, Who will take care of me in heaven? The best response for the nurse to make is: a. Who do you think will take care of you? b. Your grandparents and God will take care of you. c. Your mom will know more about that than I do. d. Why are you asking me that? ANS: A This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas the closed response in option 2 shuts off communication. The asking of a why question is not therapeutic as it calls for justification. DIF: Cognitive Level: Application REF: dm: 627 OBJ: Objective: 17 TOP: Topic: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. When dealing with a preschool-age child with a life-threatening illness, the nurse should remember that at this age the childs concept of death includes: a. That it is final b. Only a fear of separation from her parents c. That a person becomes alive again soon after death d. An understanding based on simple logic ANS: C The preschooler views death as reversible and temporary. DIF: Cognitive Level: Comprehension REF: dm: 627, Table 26-3 OBJ: Objective: 19 TOP: Topic: Nursing Care of the Dying Child KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 19. The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his extremities. The lab value that would be consistent with these symptoms is: a. Platelet count of 25,000/mm3 b. Hemoglobin level of 8 g/dl c. Hematocrit level of 36% d. Leukocyte count of 14,000/mm3 ANS: A The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential. DIF: Cognitive Level: Analysis REF: dm: 619 OBJ: Objective: 3 TOP: Topic: Idiopathic Thrombocytopenic Purpura KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly distended. Also, there is no record of a bowel movement for the last 2 days. These assessment findings suggest the possibility of: a. Peripheral neuropathy b. Stomatitis c. Myelosuppression d. Hemorrhage ANS: A Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel. DIF: Cognitive Level: Analysis REF: dm: 621 OBJ: Objective: 17 TOP: Topic: Leukemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I am so scared. The most appropriate nursing response to this comment is: a. I understand how you must feel. b. You shouldnt feel that way. c. Is this the strongest feeling youve had today? d. Tell me whats got you scared. ANS: D The nurse should encourage the adolescent to express her feelings and concerns. DIF: Cognitive Level: Analysis REF: dm: 628 OBJ: Objective: 20 TOP: Topic: Adolescent With Cancer-Fear of Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 22. The most recent blood count for a child who received chemotherapy last week shows neutropenia. The priority nursing diagnosis for this child is: a. Risk for infection b. Risk for hemorrhage c. Altered skin integrity d. Disturbance in body image ANS: A The child with neutropenia is at risk for infection. DIF: Cognitive Level: Analysis REF: dm: 620 OBJ: Objective: 17 TOP: Topic: Chemotherapy KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 23. The nurse takes into consideration an important focus of nursing care for the dying child and his/her family, which is: a. Nursing care should be organized to minimize contact with the child. b. Adequate oral intake is crucial to the dying child. c. Families should be made aware that hearing is the last sense to stop functioning before death. d. It is best for the family if the nursing staff provides all of the childs care. ANS: C Hearing is intact even when there is a loss of consciousness. DIF: Cognitive Level: Analysis REF: dm: 631 OBJ: Objective: 22 TOP: Topic: Dying Child KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 1. The nursing care of a 12-year-old child receiving radiation therapy for Hodgkins disease, should include: Select all that apply. a. Application of sunblock to the skin to prevent burning b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger e. Preparation for delay in sexual development ANS: A, B, C, D, E Sun block should be applied to skin after radiation to prevent burning. Low energy levels produce anorexia and anger in many young patients. Radiation delays the development of secondary sex characteristics and menses. DIF: Cognitive Level: Analysis REF: dm: 623 OBJ: Objective: 16 TOP: Topic: Effects of Radiation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse reviews the classic symptoms of thalassemia major (Cooleys anemia), such as: Select all that apply. a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Cardiac failure ANS: A, B, C, D, E All of the options are classic signs of thalassemia major. DIF: Cognitive Level: Comprehension REF: dm: 618 OBJ: Objective: 8 TOP: Topic: Signs of Thalassemia Major KEY: Nursing Process Step: Assessment MSC: NCLEX: Heath Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse reviews for a family how the development of synthetic recombinant antihemophilic factor has improved the management of hemophilia, because this drug: Select all that apply. a. Eliminates the need for frequent transfusions b. Can be administered by family at home c. Prevents hemorrhage d. Reduces cost of care of the hemophiliac e. Reduces risk of HIV and hepatitis A and B transmission ANS: A, B, D, E The drug can be given at home by the family. Because it supplies the missing factor, transfusions are not necessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatly reduced because hospitalizations and transfusions are not as frequently required. The drug does not prevent hemorrhage; it makes hemorrhage manageable. DIF: Cognitive Level: Analysis REF: dm: 618 OBJ: Objective: 15 TOP: Topic: Hemophilia A KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. The family of a child receiving chemotherapy for leukemia should be taught to focus on the childs care in regard to the need to: Select all that apply. a. Use a support group b. Stimulate appetite c. Maintain adequate hydration d. Delay immunizations e. Report exposure to infectious diseases ANS: A, B, C, D, E The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the drugs. Because the drugs suppress the bone marrow, children are at risk for infection, and the suppression will not allow the antibody response needed for immunization. Support groups are helpful for emotional support and realistic tips on care. DIF: Cognitive Level: Analysis REF: dm: 620 OBJ: Objective: 17 TOP: Topic: Chemotherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care COMPLETION 1. The nurse shows slides of red blood cells from a child with sickle cell anemia, noting that in addition to their sickle shape, the cells contain the abnormal element of . ANS: hemoglobin S Chapter 20. Musculoskeletal Disorders MULTIPLE CHOICE 1. In planning teaching to parents of a child with Legg-Calv-Perthes disease about the long-term effects of this disease, the nurse would include that: a. There are no long-term effects. b. The disease is self-limiting, resolving itself in a year. c. Degenerative arthritis may develop later in life. d. There is risk of osteogenic sarcoma in adulthood. ANS: C Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life. DIF: Cognitive Level: Application REF: 560 OBJ: 9 TOP: Legg-Calv-Perthes Disease KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse caring for a child in Bucks skin traction will keep the: a. Child in high-Fowlers position b. Child pulled up in bed c. Childs heel on the bed surface d. Childs feet against the foot of the bed ANS: B Bucks traction is a type of skin traction that relies on the childs weight as counter-balance The child must be kept with head elevated no more than 20 degrees, pulled up in bed, and the feet should not touch the bed surface or the foot of the bed. DIF: Cognitive Level: Analysis REF: 553 OBJ: 7 TOP: Bucks Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. When caring for a child in Bucks extension, the nurse would include: a. Positioning the child with hips flexed 90 at all times b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule ANS: C The skin exposed to frequent friction may break down. DIF: Cognitive Level: Application REF: 553 OBJ: 7 TOP: Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse reviewing the characteristics of Ewings sarcoma would point out that with Ewings sarcoma: a. Amputation is the accepted treatment. b. The disease is sensitive to radiation and chemotherapy. c. Metastasis is rare. d. The disease is more prevalent in toddlers and preschoolers. ANS: B Ewings sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize. DIF: Cognitive Level: Comprehension: Physiological Adaptation REF: 561 OBJ: N/A TOP: Ewings Sarcoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse caring for a child with Duchennes muscular dystrophy notes a characteristic manifestation, which is that the child: a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development ANS: C Frequent falling and clumsiness are clinical manifestations of Duchennes muscular dystrophy. DIF: Cognitive Level: Knowledge REF: 560 OBJ: 4 TOP: Duchennes Muscular Dystrophy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. This finding is suggestive of the type of juvenile rheumatoid arthritis. a. Pauciarticular b. Polyarticular c. Systemic d. Acute febrile ANS: A The pauciarticular form of juvenile rheumatoid arthritis is limited to four joints or fewer. DIF: Cognitive Level: Analysis REF: 562 OBJ: 8 TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse is providing instructions about how to treat a sprained ankle. The nurse will recognize the need for additional teaching when the mother states: a. Apply warm compresses to the ankle for the first 24 hours. b. Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off. c. Wrap the ankle in an Ace bandage for support. d. Keep the leg elevated when sitting. ANS: A Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation. DIF: Cognitive Level: Analysis REF: 552 OBJ: 12 TOP: Soft Tissue Injury KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse explains that Russell traction is a type of skin traction that: a. Subluxates the tibia b. Does not interfere with range of motion c. Prevents the knee from flexing d. Supplies continuous pull in two directions ANS: D Russell traction is skin traction, similar to Bucks traction, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions. DIF: Cognitive Level: Application REF: 553 OBJ: 7 TOP: Russell Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse who is checking for capillary refill on a child in Bryants traction will record adequate perfusion if the toe regains color in seconds a. 3 b. 4 c. 5 d. 6 ANS: A Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion. DIF: Cognitive Level: Analysis REF: 556 OBJ: 2 TOP: Fracture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The parent of a child with osteomyelitis asks why his child is in so much pain. The nurses response will be based on the understanding that the pain of osteomyelitis is caused by: a. The pressure of inelastic bone b. Purulent drainage in the bone marrow c. The cast applied on the extremity d. Circulatory congestion of the skin ANS: B Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain. DIF: Cognitive Level: Analysis REF: 556 OBJ: N/A TOP: Osteomyelitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. The nurse responds that antibiotic therapy will probably last for: a. 2 weeks b. 6 weeks c. 2 months d. 3 months ANS: B Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks. DIF: Cognitive Level: Application REF: 556 OBJ: 11 TOP: Osteomyelitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. The nurse, assessing the neurovascular status of a child in Russell traction, should report immediately the finding of: a. Skin warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish coloration of skin ANS: D Cyanosis or pallor noted in an extremity is an indication of circulatory impairment. DIF: Cognitive Level: Application REF: 556 OBJ: 11 TOP: Neurovascular Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. When a 13-year-old girl is diagnosed with functional scoliosis, the nurse would explain the spinal curvature defect is usually caused by: a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele ANS: B Functional scoliosis usually is caused by poor posture, and it is not a spinal disease. DIF: Cognitive Level: Application REF: 563 OBJ: 14 TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A nurse assessing a preadolescent child for scoliosis would: a. Ask the child to bend forward at the waist, and would observe the childs back for asymmetry b. Observe the gait while the child is walking forward heel to toe c. Have the child flex the knees and look for uneven knee height d. Look at the childs shoulders and hips while fully clothed ANS: A The nurse looks at the back, as the child bends forward, for general body alignment and asymmetry. DIF: Cognitive Level: Application REF: 563 OBJ: 14 TOP: Scoliosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. The nurse caring for a child in Bryants traction knows that the risk of serious complications will be reduced by ensuring that: a. Neurovascular checks are done frequently b. Ace bandages are wrapped tightly c. The baby is restrained from rolling over d. The childs buttocks are resting on the bed ANS: A The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is obstructed. DIF: Cognitive Level: Analysis REF: 562 OBJ: N/A TOP: Traction KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. The interventions that would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis would be: a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillows under the head ANS: B Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness. DIF: Cognitive Level: Application REF: 562 OBJ: 8 TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. The nurse providing instructions to an adolescent who has been fitted with a Milwaukee brace would teach the patient to: a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping. ANS: C A Milwaukee brace is worn approximately 23 hours a day over a T-shirt that protects the skin. DIF: Cognitive Level: Application REF: 563 OBJ: 14 TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The observation that may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs is: a. The child has red, green, and yellow bruises on his body. b. The childs bruises are dispersed on his head, arms, and legs. c. The child had a broken arm last year and is described as accident prone. d. The childs mother is very anxious for her son to get medical attention. ANS: A As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of what happened. DIF: Cognitive Level: Analysis REF: 568 OBJ: 6 TOP: Child Abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. The nursing diagnosis that takes highest priority for this child is: a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction ANS: A Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority. DIF: Cognitive Level: Analysis REF: 558 OBJ: 10 TOP: The Child With a Fracture in Traction KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse notes as an abnormal finding on a musculoskeletal assessment of a 4-year-old that the child: a. Has inward-turned knees while standing b. Walks on his toes c. Appears to have flat feet d. Swings his arms when walking ANS: B Toe walking after 3 years of age may indicate a muscle problem. DIF: Cognitive Level: Analysis REF: 550 OBJ: 2 TOP: Assessment of the Musculoskeletal System KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The nurse understands a difference in the childs skeletal system as compared to an adults is: a. The childs bone is less porous than adult bone. b. Bone growth is not affected by fractures. c. Bone overgrowth in healing fractures is uncommon. d. Callus formation in healing fractures occurs more rapidly. ANS: B Callus forms more rapidly in the child than the adult. DIF: Cognitive Level: Knowledge REF: 551 OBJ: 3 TOP: Differences Between the Child and Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse demonstrates how all traction devices: Select all that apply. a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb ANS: A, B, D, E Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some tractions may relieve pain, many tractions may actually cause pain. DIF: Cognitive Level: Analysis REF: 561 OBJ: 10 TOP: Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse performing a neurovascular check on a limb in traction will assess: Select all that apply. a. Pulse quality b. Degree of sensation c. Color quality d. Capillary refill e. Degree of movement ANS: A, B, C, D, E All options listed are integral components of the neurovascular assessment that is done to ensure adequate perfusion to a limb in traction. DIF: Cognitive Level: Application REF: 556 OBJ: 11 TOP: Neurovascular Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 1. The nurse explains that Bryants traction is reserved for children who weigh less than pounds. ANS: 40 DIF: Cognitive Level: Knowledge REF: 553 OBJ: 10 TOP: Bryants Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control NOT: Rationale: Bryants traction is a skin traction used in the treatment of orthopedic disorders of young children who weigh less than 40 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues. 2. The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from vigorous weight-bearing during treatment with radiation to reduce the risk of a fracture. ANS: pathological DIF: Cognitive Level: Application REF: 561 OBJ: 3 TOP: Ewings Sarcoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: The bone has lost its integrity because of the cancer and the following radiation. Excessive or vigorous weight bearing can cause a pathological fracture of the compromised bone. 3. The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to a standing position. The nurse recognizes this characteristic behavior as maneuver. ANS: Gowers DIF: Cognitive Level: Application REF: 560 OBJ: 4 TOP: Duchennes Muscular Dystrophy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: Gowers maneuver is a unique way of rising from the floor by walking up the leg in order to get the upper body erect. 4. The nurse recognizes the signs of syndrome in a child in a 90-90 traction when the toes are pale and edematous and have a very slow capillary refill. ANS: compartment Chapter 21. Dermatologic Diseases MULTIPLE CHOICE 1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-month- old because the infants skin, compared to the adults, has: a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption ANS: D The childs skin has a dramatically greater ability to absorb than does that of the adult. DIF: Cognitive Level: Application REF: 675, Figure 29-1 OBJ: 2 TOP: Skin Comparison KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse takes into consideration that children who have been diagnosed with infantile eczema have an increased risk of: a. Pneumonia b. Acne c. Sun sensitivity d. Asthma ANS: D Some children with eczema also develop asthma and hay fevertype allergies. DIF: Cognitive Level: Application REF: 680 OBJ: 4 TOP: Infantile Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The appropriate technique for the application of a topical treatment for a child with eczema is: a. Apply skin lotions in a circular motion. b. Apply prescribed ointments with a gloved hand. c. Apply as much and as frequently as relieves the symptoms. d. Choose lanolin-based ointments. ANS: B The prescribed amount of ointment is usually applied to the skin by a gloved hand in long, smooth strokes. Lanolin-based preparations should be avoided because of a possible allergy to wool. DIF: Cognitive Level: Application REF: 681 OBJ: 4 TOP: Infantile Eczema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. When the 2-day-old infant is noted to have small pustules on her skin, the nurse should: a. Report it immediately because it may be a staphylococcus infection. b. Keep the affected area dry and clean. c. Teach the parents how to care for seborrheic dermatitis. d. Chart the finding as it may be the beginning of a strawberry nevus. ANS: A A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn must be reported immediately. DIF: Cognitive Level: Analysis REF: 681 OBJ: N/A TOP: Staphylococcal Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The home health nurse discovers a family infected with pediculosis and helps the mother understand ways to start eradication of the lice, such as: a. Covering the hair with Vaseline b. Applying a soda-vinegar solution to the hair c. Combing through the hair with a vinegar-water solution d. Shampooing the hair with dish detergent ANS: C Combing a vinegar/water solution through the hair with a fine-tooth comb and then shampooing is an initial step toward eradication. DIF: Cognitive Level: Application REF: 685 OBJ: 5 TOP: Tinea Capitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. A group of football players is taking oral griseofulvin for tinea pedis. The school nurse cautions that while they are taking this medication they should avoid: a. Changing socks often b. Eating shellfish c. Alcohol consumption d. Taking corticosteroids ANS: C Consumption of alcohol while taking griseofulvin will cause severe tachycardia. DIF: Cognitive Level: Application REF: 679 OBJ: N/A TOP: Tinea Capitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. Before the 17-year-old boy starts a protocol of Accutane for his acne, the nurse should instruct him to: a. Get a prescription for oral contraceptives. b. Increase the dose if his acne worsens. c. Limit intake of chocolate, cola, and peanuts. d. Increase exposure to sunlight. ANS: A Oral contraceptives are prescribed to young males to reduce androgens, which make the skin greasy. DIF: Cognitive Level: Application REF: 679 OBJ: N/A TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. The nurse assesses a major burn as: a. Partial-thickness burn involving 25% of the body surface b. Partial-thickness burn involving 12% of the body surface c. Full-thickness burn involving 20% of the body surface d. Full-thickness burn involving 5% of the body surface ANS: C A full-thickness burn involving 10% or more of the body surface is considered a major burn. DIF: Cognitive Level: Analysis REF: 687 OBJ: 6 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. A child had a burn evidenced by pink skin and blistering. The child complains of pain and is crying. The nurse documents the burn as: a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree ANS: B A second-degree superficial burn appears blistered, moist, and pink or red. The pain associated with this burn indicates tissue viability. DIF: Cognitive Level: Analysis REF: 688, Table 29-2 OBJ: 6 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The best first action to take when a child sustains a second-degree deep thermal burn to the hand is to: a. Immerse the burned area in cold water. b. Apply ice to the burned area. c. Break any blisters that are present. d. Apply petroleum jelly to the burned skin. ANS: A First-aid treatment of a second-degree deep thermal burn is immersion of the burned area in water to halt the burning process. DIF: Cognitive Level: Application REF: 715 OBJ: 6 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. An allergy to which of the following would contraindicate the use of Silvadene as a topical agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations d. Sulfa ANS: D The use of Silvadene cream on burns is contraindicated if the patient has a sulfa allergy. DIF: Cognitive Level: Analysis REF: 692, Box 29-2 OBJ: 11 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. Which of the following would help the child with a serious burn meet nutritional needs during the subacute phase of recovery? a. Decrease calories because the child will be on bed rest and will not need as many. b. Increase calories and protein to compensate for the healing process. c. Increase fat to replace the layer of fat next to the burned skin. d. Decrease carbohydrates and starches because the pancreas is strained by the healing process. ANS: B Frequent meals and snacks high in calories, protein, and iron are needed to meet the increased metabolic needs of the child with burns. DIF: Cognitive Level: Comprehension REF: 692 OBJ: 7 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The statement made by a parent indicating an understanding of the topical application of medications for a skin condition is: a. I apply the medication after I give my child a bath. b. I rub the ointment in a circular motion over the rash. c. I increased the amount of cream because the rash was not improving. d. I use powder and cornstarch to keep the skin dry. ANS: A Absorption of topical medications is best when preparations are applied after a warm bath. DIF: Cognitive Level: Analysis REF: 681 OBJ: 9 TOP: Topical Medications KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. On the first day postburn the bodys fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. The nurse monitors the burn victim very closely for: a. Increasing intracranial pressure b. Reduced urine output c. Eschar formation d. Fluid overload ANS: B With the fluid shift associated with severe burns, the nurse must be observant for the reduction of urine, an indication of altered renal function. DIF: Cognitive Level: Analysis REF: 689 OBJ: 7 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 15. At a 2-month well-child visit, parents ask the nurse about the red area on the babys neck. They tell the nurse that the mark appeared a few weeks after birth. The nurse recognizes this skin lesion as a(n): a. Port wine nevus b. Strawberry nevus c. Exanthum d. Intertrigo ANS: B The strawberry nevus is a common hemangioma consisting of dilated capillaries in the dermal space, which may not become apparent for a few weeks after birth. DIF: Cognitive Level: Comprehension REF: 677, Figure 29-3 OBJ: N/A TOP: Congenital Lesions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infants neck and axilla. The nurse explains the cause of this rash is most likely: a. Sun exposure b. Allergic reaction c. Infection d. Heat and moisture ANS: D Miliaria, or prickly heat rash, is caused by excess body heat and moisture. DIF: Cognitive Level: Analysis REF: 677, Figure 29-5 OBJ: N/A TOP: Skin Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. What is the correct nursing response to a mother who asks, How can I get rid of the babys cradle cap? a. Rub baby oil on the infants head at night and shampoo the hair the next morning. b. Use a brush with firm bristles to loosen the scales on the babys head several times a day. c. Wash the babys head every night with a dandruff-control shampoo. d. Lubricate the babys head every morning with a small amount of olive oil. ANS: A Scales may be softened by applying baby oil to the head the evening before, and shampooing the hair in the morning. DIF: Cognitive Level: Application REF: 678 OBJ: N/A TOP: Seborrheic Dermatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. The statement made by a parent, indicating the need for further teaching about strategies to control itching for the infant with eczema, is: a. Wool is the best fabric for the babys clothing. b. I should avoid laundry detergents with fragrances. c. I put cotton gloves on the babys hands. d. The babys fingernails are kept short. ANS: A Clothing should be made of cotton. Wool is avoided because of its allergy potential. DIF: Cognitive Level: Analysis REF: 681 OBJ: 4 TOP: Infantile Eczema KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. When teaching about general skin care measures that could help prevent acne, the nurse would include: a. Eliminate chocolate, peanuts, and cola from the diet. b. Wash the face with a cleansing product frequently. c. Plan indoor activities to avoid sun exposure. d. Eat a balanced diet, and get sufficient rest. ANS: D General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help prevent exacerbations. DIF: Cognitive Level: Application REF: 679 OBJ: 3 TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 20. When the nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet, the nurse should: a. Report this sign immediately b. Place a warm towel over the extremities c. Gently sponge with cool water d. Medicate for pain ANS: D A purple flush indicates the return of sensation and causes extreme pain. DIF: Cognitive Level: Application REF: 693 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. A child is brought to the emergency department with burns on the face and chest. The nurses first priority is: a. Assessing respiratory status b. Administering pain medication c. Removing clothing d. Inserting a Foley catheter ANS: A Airway assessment and establishing an airway are the initial priorities. DIF: Cognitive Level: Analysis REF: 687 OBJ: 9 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. The adolescent girl whose acne is being treated with an antibiotic in addition to topical applications is cautioned by the nurse to expect: a. Lessened effectiveness of oral contraceptives b. Urinary burning and frequency c. Breast engorgement d. Vaginitis ANS: D Antibiotic therapy can cause a monilial vaginitis. DIF: Cognitive Level: Analysis REF: 679 OBJ: 3 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. When the nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks, the nurse documents and reports the probable complication of: a. Diverticulitis b. Stress diarrhea c. Curlings ulcer d. Perforated bowel ANS: C Curlings ulcer is a complication of burn victims resulting from the stress of their trauma. DIF: Cognitive Level: Comprehension REF: 689 OBJ: 7 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. A child is brought to the emergency department with severe frostbite. The body parts that should be warmed first are: a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso ANS: D In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the extremities. DIF: Cognitive Level: Application REF: 693 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 25. An adolescent is at the pediatricians office because he has been experiencing intense itching, particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. This symptom is associated with: a. Scabies b. Pediculosis capitis c. Tinea corporis d. Eczema ANS: A Intense itching, especially at night, is characteristic of scabies. DIF: Cognitive Level: Comprehension REF: 685 OBJ: N/A TOP: Scabies KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. To avoid diaper rash, the nurse would offer instruction to the parents to: Select all that apply. a. Use emollients. b. Expose perineum to light and air periodically. c. Use disposable diapers frequently. d. Avoid plastic pants. e. Change diaper frequently. ANS: A, B, C, D, E Keeping the skin dry and protected with emollients, changing the diaper frequently, and avoiding plastic pants will prevent diaper rash. DIF: Cognitive Level: Comprehension REF: 678 OBJ: N/A TOP: Avoiding Diaper Rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse, speaking to a group of junior high school students, informs them that acne can be exacerbated by such drugs as: Select all that apply. a. Steroids b. Dilantin c. Phenobarbital d. Aspirin e. Oral contraceptives ANS: A, B, C Long-term use of steroids, Dilantin, phenobarbital, lithium, and vitamin B12 can cause acne. DIF: Cognitive Level: Analysis REF: 679 OBJ: 3 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies COMPLETION 1. The nurse recognizes the blisters and erythema of the hands of a person recovering from frostbite as the skin disorder called . ANS: chilblain DIF: Cognitive Level: Comprehension REF: 692 OBJ: 12 TOP: Chilblain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: After exposure to cold, blisters appear on the hands and feet that are similar to a burn. These are called chilblains. 2. The nurse differentiates a type of topical medication that is an oil-based emulsion to be used on dry skin as a(n) . ANS: ointment DIF: Cognitive Level: Comprehension REF: 683, Table 29-1 OBJ: 11 TOP: Ointment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort NOT: Rationale: Ointments are oil-based emulsions that are used on dry skin. 3. A 5-year-old boy is brought to the emergency department with a second-degree burn of his entire right arm and hand, anterior trunk and genital area, and front of right thigh. The nurse assesses the BSA percentage burn as . ANS: 26% Chapter 22. Communicable Diseases MULTIPLE CHOICE 1. The nurse takes into consideration that the child most susceptible to an opportunistic infection is the one taking: a. Anticonvulsants b. A beta-adrenergic agent c. An antibiotic d. Corticosteroids ANS: D Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic infections. DIF: Cognitive Level: Analysis REF: dm: 717 OBJ: Objective: N/A TOP: Topic: Host Resistance KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. When the 8-year-old asks the nurse how she got the antibodies that kept her from getting whooping cough, the nurse explains that those shots: a. Were borrowed antibodies from another person who had whooping cough b. Gave her a tiny case of whooping cough and then she made her own antibodies c. Strengthened antibodies she was born with d. Are only temporary borrowed antibodies and she needs to have another shot every 5 years ANS: B Vaccines contain live weakened or dead organisms not strong enough to cause disease but they stimulate the body to develop an immune reaction and antibodies. This is active acquired immunity. DIF: Cognitive Level: Knowledge REF: dm: 717 OBJ: Objective: 3 TOP: Topic: Types of Immunity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse would document a rash that has erythematous circular raised lesions as: a. Macular b. Papular c. Vesicular d. Pustular ANS: B A papule is a circular, reddened elevated area on the skin. DIF: Cognitive Level: Knowledge REF: dm: 718 OBJ: Objective: 6 TOP: Topic: Rashes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse would delay the administration of DTaP when the mother says that her infant: a. Has diarrhea b. Had a temperature of 105 F from the previous inoculation c. Is teething d. Is traveling with her to Europe in a week ANS: B A contraindication to giving the DTaP vaccine is a 105 F temperature following the previous vaccination. DIF: Cognitive Level: Analysis REF: dm: 721 OBJ: Objective: 4 TOP: Topic: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. The type of precaution that is necessary when caring for a toddler with varicella is: a. Contact b. Protective c. Airborne infection d. Large droplet infection ANS: C Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubeola. Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room. DIF: Cognitive Level: Application REF: dm: 718 OBJ: Objective: 2 TOP: Topic: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. A parent is concerned because her son was exposed to varicella at preschool. The nurse would tell this parent that the incubation period for varicella is: a. 2 to 10 days b. 4 to 14 days c. 3 to 32 days d. 14 to 21 days ANS: D The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days. DIF: Cognitive Level: Knowledge REF: dm: 713, Table 31-1 OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 7. The nurse can be assured that parents understand how long a child who has varicella is contagious when they state: a. My child should stay home from school for 6 days after the pox appear. b. My child can return to school when the rash fades. c. My child must stay away from other children until all of the lesions have healed. d. My child is contagious as long as he has a fever. ANS: A The child with varicella is contagious for 6 days after the appearance of the rash. DIF: Cognitive Level: Application REF: dm: 713, Table 31-1 OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. The statement made by a sexually active adolescent girl indicating an understanding of the prevention of sexually transmitted diseases is: a. I always douche after intercourse. b. I think you can get a vaccination for STDs now. c. I insist that my partner wear a condom. d. I am protected because I take the pill. ANS: C The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual intercourse. DIF: Cognitive Level: Application REF: dm: 725 OBJ: Objective: 8 TOP: Topic: Sexually Transmitted Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. The priority nursing diagnosis for a hospitalized infant who is HIV-positive would be: a. Risk for injury b. Altered nutrition c. Impaired skin integrity d. Risk for infection ANS: D The infant who is HIV-positive has impaired immunologic functioning and is at high risk for infection. DIF: Cognitive Level: Analysis REF: dm: 725 OBJ: Objective: 7 TOP: Topic: Human Immunodeficiency Virus KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A parent of a newborn asked the nurse, When will my baby get the hepatitis B vaccine? The nurse bases a response on the knowledge that the first dose of Comvax should be given to infants born to a hepatitis B-negative mother at: a. 2 months b. 4 months c. 6 months d. 1 year ANS: B The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free hepatitis B vaccine, should be used for infants born to HBsAg-negative mothers beginning at the 2-month well-child visit. DIF: Cognitive Level: Knowledge REF: dm: 722, Figure 31-6 OBJ: Objective: 4 TOP: Topic: Immunization Schedule KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 11. The nurse would base a response to a parent about how his child got hepatitis A on the information that the child: a. Came in contact with infected blood b. Came in contact with droplets in the air c. Was bitten by a mosquito or a tick d. Ate shrimp while they were in Mexico ANS: D Hepatitis A results from ingestion of contaminated water or shellfish. DIF: Cognitive Level: Comprehension REF: dm: 714, Table 31-1 OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse use when caring for the infant? a. Large-droplet infection precautions b. Airborne-infection precautions c. Contact precautions d. Protective precautions ANS: C Contact precautions are used when the condition transmits organisms via skin-to-skin contact or indirect touch of a contaminated fomite. DIF: Cognitive Level: Application REF: dm: 718 OBJ: Objective: 2 TOP: Topic: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response for the nurse to make when the child asks, Why do you have to wear a gown and mask when you are in my room? a. Nurses and doctors wear gowns and masks because you have a condition that could be spread to others. b. The gown and mask are to protect you because you could get an infection very easily. c. Im wearing this because there are a lot of bacteria in the hospital. d. I might look scary but you wont need this after you have had medication for 24 hours. ANS: B Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly susceptible to infection. DIF: Cognitive Level: Application REF: dm: 718 OBJ: Objective: 2 TOP: Topic: Protective Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. The nurse is planning to administer immunizations at a well-child visit when a parent reports the 18-month-old child is allergic to eggs. The vaccine that would be contraindicated is: a. Influenza b. Inactivated polio vaccine c. Diphtheria, tetanus, acellular pertussis d. Hepatitis B ANS: A The influenza vaccine should not be given to children who have an allergy to eggs. DIF: Cognitive Level: Analysis REF: dm: 720 OBJ: Objective: 3 TOP: Topic: Nurses Role in Immunizations-Allergy KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 15. The nurse would choose to administer the immunization injection of: a. DTaP subcutaneously b. Hib vaccine prepared in a separate syringe c. Varicella intramuscularly d. Varicella 1 week after the MMR vaccine ANS: B Hib vaccine must be given in a separate syringe from other vaccines administered at the same time. DIF: Cognitive Level: Analysis REF: dm: 722, Figure 31-6 OBJ: Objective: 3 TOP: Topic: Nurses Role in Immunizations KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. A child was sent to the school nurse because of a rash. The nurse noted the rash was present on the trunk, extremities, and face. The childs cheeks were bright red. The nurse is aware this type of rash is consistent with: a. Measles b. Roseola c. Varicella d. Fifth disease ANS: D When a child has fifth disease, the child has a generalized rash and the cheeks have a slapped cheek appearance. DIF: Cognitive Level: Application REF: dm: 713, Table 31-1 OBJ: Objective: 6 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 17. The nurse determined the parent understood the information when he stated: a.ll hI ave my son wear dar k clothing on his hike. b. We should all get the Lyme disease vaccine before our trip. c. Ill get a prescription for amoxicillin to take with us. d. We will wear long pants and long-sleeved shirts in the woods. ANS: D People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites. DIF: Cognitive Level: Application REF: dm: 715, Table 31-1 OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 18. An adolescent is taking tetracycline for a sexually transmitted disease. The nurse would stress in the instruction about this medication to: a. Finish all of the medication. b. Get plenty of fresh air and sunlight. c. The medication should be taken with food. d. Take an antacid if the medication causes an upset stomach. ANS: A The nurse would teach the adolescent to take all of the prescribed medication to avoid making the microorganism resistant to tetracyclines. DIF: Cognitive Level: Application REF: dm: 724, Table 31-3 OBJ: Objective: 8 TOP: Topic: Sexually Transmitted Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 19. The nurse explains to the parents that their child is in the prodromal stage of varicella. This means that the child: a. Is now immune to varicella b. Has varicella, but has not yet broken out c. Is infected with varicella, but is not contagious d. Does not have varicella, but has been exposed to it ANS: B The prodromal stage is the initial stage of the communicable disease in which the child is infected and contagious, but does not yet have outward signs of the disease. DIF: Cognitive Level: Application REF: dm: 716 OBJ: Objective: 1 TOP: Topic: Prodromal Period KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. In giving care, the nurse is aware that safe handling of body substances is essential. Body substances that require safe handling are: Select all that apply. a. Emesis b. Saliva c. Feces d. Semen e. Blood ANS: A, B, C, D, E All the options listed are considered body substances that are moist secretions capable of containing microorganisms. DIF: Cognitive Level: Comprehension REF: dm: 716 OBJ: Objective: 1 TOP: Topic: Body Substances KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. The well-child clinic nurse will prepare to give a healthy 2-month-old inoculations for: Select all that apply. a. DTaP b. Hib c. IPV d. MMR e. PCV ANS: A, B, C, E All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps, measles, rubella are not expected until the child is 1-year-old. DIF: Cognitive Level: Application REF: dm: 722, Figure 31-6 OBJ: Objective: 3 TOP: Topic: Inoculations for a 2-Month-Old KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control [Show More]

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