pedi fall 18 final exam McKinney

The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, O.K.?" The nurse should: 1 start the IV line because allowing the child to manipulate the nurse is bad. 2 start the IV line because unlimited procrastination results in heightened anxiety. 3 postpone starting the IV line until the child is ready so that the child experiences a sense of control. 4 postpone starting the IV line until the child is ready so that the child's anxiety is reduced

. 2 Intravenous antibiotics are a priority action for the nurse. A short delay may be possible to allow the child some choice, but a prolonged delay only serves to increase the anxiety. The nurse should start the IV line, recognizing that the child is attempting to gain control. If the timing of the IV line start was not essential for the start of IV antibiotics, postponing might be acceptable. The child may never be ready. The anxiety is likely to increase with prolonged delay.

Which nerve is the nurse assessing when testing the VII cranial nerve? 1 Facial nerve 2 Vagus nerve 3 Optic nerve 4 Trochlear nerve

1 Assessment of the cranial nerves is an important area of the neurological assessment. The facial nerve is referred to as the VII cranial nerve. The nurse assesses the function of the facial muscles and the anterior two thirds of the tongue (sensory). The vagus is the X cranial nerve and it controls the muscles of the larynx, pharynx, and some organs of the gastrointestinal system. The optic nerve is the cranial nerve II and controls the vision and the rods and cones of the retina. The trochlear nerve is the cranial nerve IV and controls the superior oblique muscle.

A mother tells the nurse that she will visit her 2-year-old son tomorrow about noon. During the child's bath, he asks for mommy. The nurse's best reply is: 1 "Mommy will be here after lunch." 2 "Mommy always comes back to see you." 3 "Your mommy told me yesterday that she would be here today about noon." 4 "Mommy had to go home for a while, but she will be here today."

1 Because toddlers have a limited concept of time, the nurse should translate the mother's statement about being back around noon by linking the arrival time to a familiar activity that takes place at that time. Saying that the child's mother will always return does not give the child any information about when his mother will visit. Twelve noon is a meaningless concept for a toddler. Saying generally that the child's mother will visit does not give the child specific information about when his mother will visit.

A child has recently been admitted to the hospital. The child's parents have not yet arrived at the hospital. What behavior is the child exhibiting that leads the nurse to believe the child is exhibiting the stage of protest? The child: 1 Screams and hits the nurse. 2 Is withdrawn from others. 3 Has the habit of bed-wetting. 4 Sits in a corner with a toy.

1 Children often undergo separation anxiety when they are separated from their parents. This separation anxiety manifests in different stages such as protest, despair, and detachment. Protest is the first stage of separation anxiety, during which the child screams, cries, or hits the other person for separating him or her from the parents. After this stage, the child enters the stage of despair, where the child begins to withdraw from others and stay depressed. During this stage, the child starts wetting the bed and sucking the thumb because of fear and anxiety. After the stage of despair, the child enters the stage of detachment. The child starts interacting with strangers and takes an increased interest in the surroundings or sits in a corner and plays with a toy.

During an otoscopic examination on an infant, in which direction is the pinna pulled? 1 Down and back 2 Down and forward 3 Up and forward 4 Up and back

1 Correct position for an infant's ear examination is to pull the pinna down and back. Pulling the pinna down and forward is the correct position for a child age 3 years and over. Pulling the pinna up and forward or up and back will not allow sufficient visualization of the ear.

A patient reports dizziness, lightheadedness, and feeling faint on getting up from a bed or chair. What could be the reason for such symptoms? 1 A sudden decrease of 20 mm Hg in systolic blood pressure (SBP) and 10 mm Hg in diastolic blood pressure (DBP) 2 A sudden decrease of 10 mm Hg in systolic blood pressure (SBP) and 20 mm Hg in diastolic blood pressure (DBP) 3 A sudden elevation of 20 mm Hg in systolic blood pressure (SBP) and 10 mm Hg in diastolic blood pressure (DBP) 4 A sudden elevation of 10 mm Hg in systolic blood pressure (SBP) and 20 mm Hg in diastolic blood pressure (DBP)

1 Dizziness (vertigo), feeling faint (syncope), and lightheadedness are manifestations of postural hypotension or orthostatic hypotension. A sudden drop of 20 mm Hg in SBP and 10 mm Hg in DBP causes the manifestations of orthostatic hypotension. A sudden drop of 10 mm Hg in SBP and 20 mm Hg in DBP cannot occur because SBP always drops more than DBP. A sudden elevation of 20 mm Hg in SBP and 10 mm Hg in DBP, and a sudden elevation of 10 mm Hg in SBP and 20 mm Hg in DBP, do not present with these symptoms.

Which method should the nurse use to view the tonsils and oropharynx of a cooperative 6-year-old child? 1 Ask child to open mouth wide and say "aah." 2 Ask child to open mouth wide and then place the tongue blade in the center back area of the tongue. 3 Examine the mouth when the child is crying to avoid use of tongue blade. 4 Pinch nostrils closed until the child opens his or her mouth and then insert the tongue blade.

1 If the child is cooperative, the child can open his or her mouth and move the tongue around for the examiner. A tongue blade is not necessary to visualize the tonsils and oropharynx if the child cooperates. During crying, there is insufficient opportunity to completely visualize the tonsils and oropharynx. It is inappropriate to pinch the nostrils closed, especially with cooperative children.

The nurse is assessing the neurological function of an infant. The elicited response is partial flexion of the forearm. Which reflex is elicited by this response? 1 Biceps reflex 2 Triceps reflex 3 Patellar reflex 4 Achilles reflex

1 Testing reflexes is an important part of the neurological examination. The child's arm is held by placing the partially flexed elbow in the examiner's hand with the examiner's thumb over antecubital space. The normal response is partial flexion of the forearm. The triceps reflex is elicited by placing the child in a supine position with the forearm resting over the chest and stimulating the triceps tendon. Normal response is partial extension of the forearm. During the assessment of the patellar reflex, the child sits on the edge of the examining table with the lower legs flexed at the knee and dangling freely. The patellar tendon is tapped and the response is partial extension of the lower leg. When the nurse is assessing the Achilles reflex, the child is placed in the sitting position and the foot is supported lightly in the examiner's hand. The Achilles tendon is struck and the normal response is plantar flexion of the foot.

A child is scheduled for a tonsillectomy and is afraid of the surgery. The child asks the nurse, "Will I need another operation when I have a sore throat again?" Which response should the nurse give to the child? 1 "Once your tonsils are taken out, you will not need the surgery again." 2 "You will need to repeat the surgery when you have another infection." 3 "You will need to have another surgery when you turn 14 years old." 4 "Once your tonsils are fixed, you will not have any more sore throats."

1 The child does not have enough knowledge about the tonsillectomy. Therefore the child may have fear about the surgery. The nurse should explain to the child that once the tonsils are removed, they do not need "fixing" again. It helps relieve the child's fear about the operation, and the child may feel comfortable. Once the tonsillectomy has been done in the child, a second operation is not required after another throat infection. There will actually not be a need for repeating the operation at any age. The child needs to be instructed that there may be other sore throats in the future. However, the child needs to be reassured that future sore throats will not require surgery.

The nurse is preparing to administer a vaccine to a child. The child is refusing to take the vaccination because of fear of bleeding. What should the nurse do in this situation? 1 Tell the child he or she can pick the bandage color. 2 Tell the child bleeding will stop in a few seconds. 3 Request a staff member sit beside the child. 4 Give a favorite toy to the child for distraction.

1 The child is refusing to take vaccination because of fear of bleeding and pain. The nurse should ask the child to select the color of the bandage to be used. This reassures the child and will make him or her feel better. Even if the nurse tells the child that the bleeding will stop when the needle is removed, it does little to help relieve the child's fear. The nurse should not scold the child in a firm tone because the child may get frightened. Giving a favorite toy to the child for playing is not helpful for relieving the fear. A favorite toy may help the child sleep at night. Requesting a staff member sit beside the child may not be helpful for relieving the child's fear. It may be needed to help hold the child still during a procedure.

A child is hospitalized for treatment of the flu. Once the child's parents leave, the child starts crying, looks for parents, attempts to leave, refuses to take medicine, hits other children, and breaks toys. What should the nurse conclude from the child's behavior? The child is in the: 1 Protest stage. 2 Despair stage. 3 Denial stage. 4 Detachment stage.

1 The child's behavior indicates that the child is in the protest stage of separation anxiety. The child is less able to cope with separation because of stress from the illness and wants to stay with the parents. The child expresses anger indirectly by showing behavioral changes. These behavioral changes are observed in the protest stage of separation anxiety. In the despair stage, the child appears less active, depressed, and uninterested in play and refuses to eat food. The denial stage is also called the detachment stage. In this stage the child is interested in the surroundings, plays with others, and forms new but superficial relationships with others.

Guidelines for a nurse using an interpreter in developing a care plan for an 8-year-old admitted to rule out epilepsy include: 1 explaining to the interpreter what information is necessary to obtain from the patient and family. 2 encouraging the interpreter to ask several questions at a time to make the best use of time. 3 not giving the interpreter too much information so the interview evolves. 4 discouraging the interpreter and patient from discussing topics that are deemed irrelevant to the original intent of the interview.

1 The interpreter should be given guidance about what information is necessary to obtain during the interview. One question should be asked at a time, leaving sufficient time for the family to answer. The interpreter should not have to guess what to ask and what information to obtain during the interview. The interpreter should gain as much information from the family as they are willing to share based on the questions posed. Limits should not be placed on the interview.

The nurse is obtaining the admission history of a recently admitted adolescent. The nurse notes the patient requires help inserting contact lenses. Under which functional health pattern should the nurse record this observation? 1 Activity-exercise pattern 2 Cognitive-perceptual pattern 3 Nutrition-metabolic pattern 4 Health perception-health management pattern

1 The nurse records the admission history of the patient in terms of different functional health patterns. This helps in documenting all the required information about the patient. The patient requires help inserting his or her contact lenses. This implies that the patient needs support to perform an activity. The nurse should record this information under the activity-exercise pattern. The cognitive-perceptual pattern recognizes the cognitive development in the child and includes information such as defects in vision, hearing, or grading in the school. The nutrition-metabolic pattern is used in the assessment of nutrition in the patient, food allergies, and food intake habits. The health perception-health management pattern reports the medication and the health history of the child.

The nurse is assessing a child's nutritional status and notices that the child's immune system is decreased, and the child is fatigued and has low energy levels. The child's skin is dry and scaly. The child is not interested in eating anything and the stomach is bloated. What does the nurse interpret from these findings? The child is: 1 malnourished. 2 very overweight. 3 at risk for cancer. 4 well nourished.

1 The findings obtained from the nutritional assessment of the child indicate that the child is malnourished. The signs and symptoms of malnutrition are based on deficiencies. Fatigue, low energy levels, dry and scaly skin, and the bloating in the stomach are generalized symptoms that indicate that the child is malnourished. If the child is overweight or obese, the child will have irregular eating patterns, abnormal body growth, and will have a higher body weight with respect to height. There is no evidence of cancer in the question. If the child is well nourished, the child would not show signs such as fatigue and scaly skin.

The nurse plans to assess the role-relationship pattern in a child. Which questions should the nurse ask the parents? Select all that apply. 1 "Does the child have any security objects at home?" 2 "How do you handle discipline problems at home?" 3 "Have you ever noticed that your child sweats a lot?" 4 "How does your child usually handle disappointments?" 5 "Have any major changes in the family occurred lately?"

1, 2, 5 For assessing the role-relationship pattern in the child, the nurse should ask the parents about any security objects the child may have at home that provide comfort, discipline problems of the child, and family changes. From this information, the nurse can understand the relationship between the parents and the child. Information about sweating gives an idea about the elimination pattern in the child. Information about the disappointment handling potential of the child gives an idea about the child's coping-stress tolerance pattern.

A nurse is conducting a health history on an adolescent. Components of the health history include: Select all that apply. 1 sexual history. 2 review of systems. 3 physical assessment. 4 growth measurements. 5 family medical history.

1, 2, 5 Sexual history is a component of the health history. Review of systems is a component of the health history. Review of family medical history is a component of the health history. Physical assessment is a component of the physical examination. Growth measurements are a component of the physical examination.

A hospitalized child is being released for home health care. What suggestions should the nurse provide to prepare the family for transporting the child home? Select all that apply. 1 Take a basin in case of vomiting 2 Avoid using the restraint system 3 Keep a blanket and pillow in the car 4 Discourage the use of a straw for drinking fluids 5 Administer prescribed pain medication before leaving

1, 3, 5 The parents should use a basin or plastic bag for managing vomiting in the child. A blanket and pillow should be kept in the car to provide comfort. Pain medication can be administered before leaving to provide a pain-free journey home. The use of a car safety restraint system should be encouraged for the child's safety. Also, the use of a straw for drinking fluids should be encouraged except for children with oral facial surgeries.

After assessing the apical pulse of a child, the nurse documents the grade of the pulse as +2. What does this finding indicate? 1 The pulse is not palpable. 2 The pulse is strong and pounding. 3 The pulse is difficult to palpate and may be obliterated by pressure. 4 The pulse is easy to palpate and is not easily obliterated by pressure.

3 The grading of pulses is done on the basis of the strength of the pulsations. If the pulse is difficult to palpate and may be obliterated by pressure, then the grade of the pulse is +2. If the pulse is not palpable, then the grade of the pulse is 0. If the pulse is strong and pounding, then the grade of the pulse is +4. If the pulse is easy to palpate and is not easily obliterated by pressure, then the grade of the pulse is +3.

The nurse is discharging a young child from the hospital. The nurse should instruct the parents to look for which posthospital child behaviors? Select all the apply. 1 Tendency to cling to parents 2 Jealousy toward others 3 Demands for parents' attention 4 Anger toward parents 5 New fears such as nightmares

1, 3, 5 Young children's posthospital behaviors include: They show initial aloofness toward parents; this may last from a few minutes (most common) to a few days. This is frequently followed by dependency behaviors: tendency to cling to parents; demands for parents' attention; vigorous opposition to any separation (e.g., staying at preschool or with a babysitter). Other negative behaviors include: new fears (e.g., nightmares); resistance to going to bed, night waking; withdrawal and shyness; hyperactivity; temper tantrums; food peculiarities; attachment to blanket or toy; regression in newly learned skills (e.g., self-toileting). Posthospital behaviors for older children include negative behaviors: emotional coldness followed by intense, demanding dependence on parents; anger toward parents; jealousy toward others (e.g., siblings).

Which behavior would most likely be manifested in a young child experiencing the protest phase of separation anxiety? 1 Inactivity 2 Clings to parent 3 Depressed, sad 4 Regression to earlier behavior

2 In the protest phase, the child aggressively responds to separation from parents (such as clinging to a parent). Inactivity is characteristic of despair. Depression and sadness are characteristics of despair. Regression to earlier behavior is characteristic of despair.

What explains the importance of detecting strabismus in young children? 1 Color vision deficit may result. 2 Amblyopia (a type of blindness) may result. 3 Epicanthal folds may develop in affected eye. 4 Ptosis may develop secondarily.

2 Amblyopia may develop if the eyes do not work together. Color vision depends on rods and cones in the retina, not muscle coordination. The brain may ignore the visual cues from one eye, resulting in blindness. Epicanthal folds are present at birth. Ptosis, or drooping eyelids, is not related to strabismus (or cross-eyes).

The nurse asks a child to "blow out" the light on an otoscope five to six times in a row. The nurse is auscultating the breath sounds over the trachea near the suprasternal notch. What pattern of inspiratory and expiratory breath sounds does the nurse hear? 1 Both the inspiratory and expiratory phases are equal. 2 The inspiratory phase is short, while the expiratory phase is long. 3 The inspiratory phase is long, while the expiratory phase is short. 4 Both the inspiratory and expiratory phases are too long.

2 Bronchial breath sounds can only be heard over the trachea near the suprasternal notch. These breath sounds have a short inspiratory phase and a long expiratory phase. The child is blowing out continuously so this can be clearly auscultated. The inspiratory and expiratory phases may not be equal because the child takes short inspirations and exhales deeply to blow out the light. When auscultating vesicular lung sounds over the lung fields, the inspiratory phase is long and the expiratory phase is short. The inspiratory and expiratory phases cannot both be too long.

The nurse works in a pediatric unit. Which child would have an increased vulnerability to the stresses of hospitalization? 1 A female child 2 A child with a difficult temperament 3 A child with an average intelligence 4 A child older than 6 years of age

2 Hospitalization is a stressor in children and so they may react differently to it. Certain children are more susceptible to the stressful effects of hospitalization than others. Children who have difficult temperament may not readily adjust with the unfamiliar environment of the hospital. These children may experience adverse effects of hospitalization. Female children are able to withhold stress more when compared to male children and thus are less likely to experience stressors. Children with average intelligence may be able to understand their condition and the importance of hospitalization and thus may be more adaptable. Children with lower IQ would not understand the purpose of hospital admission and thus would be extremely stressed due to hospitalization. Children who are older than 6 years of age have developed the maturity to understand their condition and the purpose of hospitalization. Thus, they would be more adaptable to their condition, and experience less stress related to hospitalization.

In what position should the nurse place the child in order to examine the child's mouth and throat? The nurse tells the child to: 1 Copy the nurse and do what the nurse is doing in front of the mirror. 2 Tilt head back slightly and take deep breaths through the mouth. 3 Turn head sideways, say "ahh," and keep the mouth open. 4 Tilt head backward, hold the nose tip upward, and say "ahh."

2 If the child is older and cooperative, the nurse can examine the mouth and throat with the help of a tongue blade. However, in younger children it is difficult. The nurse should demonstrate the procedure on a parent or puppet and explain how important it is to let the nurse look in their mouth. The nurse should instruct the child to tilt the head back slightly, take a deep breath through the mouth, and then hold the breath. This action lowers the tongue to the floor of the mouth and allows the nurse to examine the mouth and throat. Instructing the child to follow the same actions as the nurse would not help the nurse to visualize the mouth. If the nurse tells the child to say "ahh" and keep the mouth open, the child may not cooperate or the child may close the mouth due to pain. If the child turns the head sideways, the nurse may not be able to assess the mouth and throat. If the nurse tells the child to tilt the head backward, hold the nose tip upward, and say "ahh", the nurse may not be able to view the mouth. This position helps the nurse to assess the nose.

The nurse has been assigned to the pediatric respiratory unit. What is the preliminary requirement for the nurse to evaluate improvement in the respiratory function of the child with treatment? 1 The child's feedback 2 The baseline data 3 The parents' opinion 4 The primary health care provider's opinion

2 It is impossible to evaluate the improvement in the respiratory function of the child without having any baseline data. The child's feedback provides only subjective assessment. Evaluation of respiratory system function requires formal knowledge of the respiratory system assessment. Therefore, parent opinion is not reliable for improvement in the child's respiratory function. Evaluation of the improvement in the respiratory function requires objective assessment. Obtaining the primary health care provider's opinion is a type of subjective assessment.

The nurse is teaching the nursing students about functions of play in the hospital. Which statement made by the nursing student indicates the need for further teaching? "Play: 1 Can lessen the stress of separation from the family." 2 Makes the child nervous in a strange environment." 3 Helps the child develop a positive attitude for others." 4 Provides an expressive outlet for the child's creative ideas."

2 Play is one of the most important aspects of a child's life and one of the most effective tools for managing stress. It is helpful for the child to relieve stress. It is also essential for the child's mental, emotional, and social well-being. Play does not make the child anxious in an unfamiliar environment. It helps the child feel more secure in a strange environment. Play lessens the stress of separation from the family because the child is busy. During play, the child communicates with others, which helps develop a positive attitude toward others. It also stimulates thinking in the child by allowing the child to express creative ideas.

Which type of temperature recording should a nurse use for an accurate temperature reading on a 3-month-old infant? 1 Oral 2 Rectal 3 Axillary 4 Tympanic

2 Rectal temperature recording provides the most accurate core body temperature measure for infants from birth to 2 years of age. Thus, the nurse should use the rectal temperature measurement for the infant. The infant would not be able to hold the thermometer under the tongue. and thus oral measurement should not be used for a 3-month-old infant. Axillary temperature recording is the most convenient temperature recording method in infants. However, it does not give an accurate temperature reading. Tympanic method of temperature recording is not suitable for children younger than 2 years of age because it can damage the tympanic membrane of the ear.

When admitting a child to the inpatient pediatric unit, the nurse should assess for which risk factors that can increase the child's stress level associated with hospitalization? Select all that apply. 1 Mild temperament 2 Lack of fit between parent and child 3 Below-average intelligence 4 Age 5 Gender

2, 3, 4, 5 Risk factors for increased stress level of a child to illness or hospitalization: "Difficult" temperament; Lack of fit between child and parent; Age (especially between 6 months and 5 years old); Male gender; Below-average intelligence; Multiple and continuing stresses (e.g., frequent hospitalizations).

The nurse is educating a group of parents and children in the pediatric ward about the benefits of ambulatory care. What benefits does the nurse discuss with the group? Select all that apply. 1 Improved care 2 Increased cost-saving 3 Reduced chances of infection 4 Ambulatory care is lesser challenging 5 Minimum stressors of hospitalization

2, 3, 5 Ambulatory care is associated with an increased cost-saving as compared to hospital admissions, since there are no admission-related costs. Ambulatory care is associated with lesser chances of acquiring infections due to limited exposure to health care facilities. Ambulatory care is devoid of the stressors of hospitalization. There is deficient care due to the absence of qualified medical person for supervision. Ambulatory care is more challenging when compared to hospitalization as the child and the parents need to rely mostly on themselves for providing care to the child.

The nursing student is caring for a child admitted to the hospital. The nursing student asks the nurse instructor, "How can we keep the child's routine habits while he is in the hospital?" What would be the best response by the nurse instructor? Select all that apply. "Ask the parents: 1 "About the use of any herbal therapies." 2 "When the child goes to sleep at night." 3 "What foods the child prefers to eat." 4 "How the child's grades are in school." 5 "Which toy the child plays with at home."

2, 3, 5 The nurse should assess the child's usual health habits at home to promote a more normal environment in the hospital. This includes the child's sleep-rest, nutritional-metabolic, and activity-exercise patterns. The nurse would assess the sleep-rest pattern by asking when the child goes to sleep at night. Assessing the nutritional-metabolic pattern would include asking about food preferences. The nurse should also ask what toy the child plays with at home as part of the activity-exercise pattern. These will help the nurse plan individualized care for the child. History about herbal and complementary therapy helps in preventing drug-drug interaction and severe adverse effects.

After assessment, the nurse notices that a child is in the detachment stage of separation anxiety. Which behavioral changes would the nurse observe in the child? Select all that apply. 1 Refuses to eat, drink, or get out of the bed 2 Shows an increased interest in the surroundings 3 Tries to leave the hospital to find the parents 4 Begins to form new relationships with others 5 Interacts with strangers or familiar caregivers

2, 4, 5 Detachment is the third stage of separation anxiety. It is also referred to as the denial stage. In this stage the child begins to take an interest in the surroundings. The child also forms new but superficial relationships with others and becomes more interested in interacting with strangers or familiar caregivers. The child's behavior indicates that the child has finally adjusted to the loss of the parents. This is a serious stage because reversal of the potential adverse effects is less likely to occur after detachment. Refusing to eat, drink, and get out of bed are characteristics of the despair stage of separation anxiety. Attempting to leave the hospital to find the parents is observed in protest stage of separation anxiety.

Which statement is true concerning the increased use of telephone triage by nurses? 1 Telephone triage has led to an increase in health care costs. 2 Emergency department visits are not recommended by nurses and thus are not a Perry component of telephone triage. 3 Access to high-quality health care services has increased through telephone triage. 4 Home care is often recommended when it is not appropriate.

3 The judicious use of telephone triage has decreased the number of unnecessary visits, allowing time for improved care. Health care costs have decreased because of fewer visits to emergency departments. Based on the response to screening questions, the triage nurse determines whether the child needs to be referred to emergency medical services. The nurse can then initiate the call if needed. Home care is recommended only when indicated on the basis of the screening questions.

19. What is critical for the nurse to know when using restraints on a child? a. Use the least restrictive type of restraint. b. Tie knots securely so they cannot be untied easily. c. Secure the ties to the mattress or side rails. d. Remove restraints every 4 hours to assess skin.

ANS: A Feedback A When restraints are necessary, the nurse should institute the least restrictive type of restraint. B Knots must be tied so that they can be easily undone for quick access to the child. C The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. D Restraints are removed every 2 hours to allow for range of motion, position changes, and assessment of skin integrity.

A parent reports to the nurse that a small object became stuck in the child's ear while playing. Arrange the nursing interventions in the correct order for the removal of the foreign body. The nurse: 1. reassures the child that removal of a foreign body does not cause pain. 2. determines what is lodged in the ear canal by using a flashlight. 3. removes the foreign body from the ear with forceps, suction, or irrigation. 4. shows the foreign object to the child and parents and reassures them. 5. positions the child under a clear light and is able to visualize the ear canal. 6. prepares the tray with equipment for the removal of the foreign body.

2, 6, 1, 5, 3, 4 Foreign bodies in the ear are common, and removal of these foreign bodies prevents infection and ear damage. Six steps are involved in the removal of a foreign body. At first, the nurse determines what type of foreign object there is in the ear canal, using a flashlight or sometimes using an otoscope. After identifying the object as soft or hard, vegetative or an insect, the next step is to keep the equipment tray ready for the removal of the foreign body. The nurse should reassure the child that it will not be painful. This will help reduce stress and increase cooperation. Proper positioning of the child is an important step in the removal because movement of the child may push the foreign body further into the ear canal and hurt the child. The nurse then removes the foreign body completely without leaving any parts or breaking the foreign object. In the last step, the nurse shows the foreign body to the child and parents, and reassures them that there is no damage. The nurse will also teach the parents to administer any medications prescribed by the health care provider.

A child who has undergone orofacial surgery is getting discharged. The nurse teaches the parents about how to safely transport the child on the way home. Which statement made by the parents indicates a need for additional teaching? "We should: 1 Have a blanket and pillow for our child for the car ride home." 2 Have a plastic bag for our child in case of nausea and vomiting." 3 Use a cup with a lid and a straw for giving fluids to our child." 4 Make sure our child has pain medication before discharge."

3 Children who undergo orofacial surgery should not use a straw for drinking fluids because it can damage the surgical site. Therefore the parents should not use cup with a lid and a straw for giving fluids to the child. The parents should bring a blanket and pillow for the child in the car so that the child can sit or sleep properly. Parents should bring a plastic bag, which will be helpful if the child becomes nauseated or vomits. The parents should give prescribed pain medication to the child before leaving the facility for relieving pain.

The nurse is assessing the nutritional status of a child and notices that the child is deficient in vitamins B6 and B12. What clinical signs does the nurse identify in the child? 1 Muscle weakness, anemia, neurological damage, and alopecia 2 Hardening and scaling skin, pruritis, jaundice, and crackled lips 3 Fatigue, pale skin, sore tongue, bleeding gums, and mood swings 4 Weakened tooth enamel, soft bones, anxiety, and mood swings

3 Deficiency of vitamins B6 and B12 causes symptoms such as tiredness and fatigue, pale skin, sore tongue, bleeding gums, stomach upset, rapid heartbeat, and mood swings. Muscle weakness, anemia, neurological damage, and alopecia are the primary symptoms due to the deficiency of vitamin E. Excess of vitamin A may cause hardening and scaling of skin, pruritis, jaundice, hair loss, and hard tender lumps in occiput. Defective enamel on teeth, bleeding gums, and softened bones are generalized symptoms of both vitamin C and D deficiency.

Why does the nurse ask the parents of a hospitalized child to bring the child's blanket from home? 1 To alleviate any fears in the child 2 To decrease any allergic reactions 3 To provide comfort for the child 4 To keep the child warm at night

3 If the parents cannot stay with the child in the hospital, the nurse may ask the parents to leave an article such as a blanket or toy from home. This is because young children associate such inanimate objects with significant people, and they gain comfort and reassurance from these possessions. When a child is frightened, the nurse should provide physical contact to ease the child. If the child is allergic to the linens at the hospital, it would be the hospital's responsibility to find alternative bedding. There are plenty of blankets available in the hospital, so the parents would not bring the blanket to keep the child warm.

The nurse is measuring the vital signs of a child. When does the nurse send the child for immediate referral and treatment? If the blood pressure is: 1 Over 90th percentile, plus 5 mm Hg 2 Over 95th percentile, plus 5 mm Hg 3 Over 99th percentile, plus 5 mm Hg 4 between 95th to 99th percentile, plus 5 mm Hg

3 Measurement and interpretation of blood pressure in children requires careful attention and correct procedures. If the child's BP is over 99th percentile, plus 5 mm of Hg, prompt referral is needed. Even if the child is symptomatic, immediate referral and treatment are indicated. If the BP is over 90th percentile, the BP measurement should be repeated twice at the same office visit and an average of systolic blood pressure (SBP) and diastolic blood pressure (DBP) are to be used to confirm the reading. If the BP is over 95th percentile, the BP should be further assessed based on two more measurements. When all the recordings confirm elevated BP, treatment is indicated. If the BP is between 95th to 99th percentile, plus 5 mm Hg, the BP measurement should be repeated twice. If it is confirmed, then referral and treatment is started.

The nurse develops a plan of care based on the information documented in a child's admission assessment. The nurse instructs the health care team that they should not leave the room until the child falls asleep. What information documented under the self-perception-self-concept pattern would necessitate this nursing intervention? The child has: 1 Nightmares. 2 Disturbed sleep patterns. 3 A fear of sleeping alone. 4 The habit of bed-wetting.

3 The child has fear of sleeping alone in the room. This information is usually noted under the self-perception—self-concept pattern of the nursing history. The nurse tries to comfort the child's fear of sleeping alone by being present until the child falls asleep. Nightmares can be managed by comforting the child and preventing specific fears. Nightmares and disturbed sleep may be brought on by hospitalization and may improve once the child adapts himself or herself to the new environment. Bed-wetting is common in younger children but needs further evaluation in older children.

An infant is born with bladder exstrophy. What action by the nurse is the priority? a. Obtain surgical consent for the corrective operation. b. Cover the exposed bladder with non-adherent plastic wrap. c. Insert an indwelling catheter to collect all the urine. d. Obtain consent for genetic testing on parents and infant.

ANS: B In bladder exstrophy, the bladder is outside the body and must be covered with a non-adherent plastic wrap until surgical correction. This is the priority action. Consent will be obtained prior to surgery. A catheter is not needed. Genetic testing is not necessarily done.

The registered nurse asks a student nurse to measure the temperature of a 2-year-old child. Through which route does the student nurse measure the child's temperature? 1 Oral 2 Rectal 3 Axillary 4 Tympanic

3 The nurse can measure temperature at several body sites, but the axillary route of temperature screening is the recommended site for a toddler. This is a noninvasive and easy way to measure body temperature. An axillary thermometer is placed in the central position under the axilla and the arm is held tight against the chest wall. The oral route is not recommended until children can hold the thermometer under their tongue. The rectal route is recommended for infants when a definitive temperature reading is needed. The tympanic route of temperature screening is recommended in children older than 5 years, and requires good access to the child's ear.

The nurse is caring for a child with cancer. What should the nurse ask the child's parents about in order to obtain information about the child's coping-stress tolerance pattern? 1 "How do you both handle discipline problems at home?" 2 "Have you ever noticed if your child has many friends?" 3 "How does your child usually handle disappointment?" 4 "Who will be staying with your child at the hospital?"

3 The nurse should ask the child's parents about how the child usually handles disappointment. This can help the nurse understand the coping-stress tolerance pattern of the child. It is also helpful for identifying stressors in the child. It is important to know how discipline problems are managed in the child. This helps to know about the child and parent role-relationship pattern. When the nurse asks about the child's friends, it is to assess the child's role and relationship patterns outside the home. The nurse can understand the role and relationship pattern between the parents and child after knowing who will stay in the hospital with the child.

The nurse is assessing the physical status of a child who presents with a slumped, careless, and apathetic pose. What does the nurse interpret about the child? The child: 1 is experiencing intense pain. 2 may have some hearing loss. 3 may have low self-esteem. 4 has feelings of self-worth.

3 The nurse should observe the posture, position, hygiene, and type of body movements when assessing the child. A slumped, careless, and apathetic pose are characteristics of a child with low self-esteem or feelings of rejection. The child with pain may be guarded and look anxious due to the inability to handle the pain. A child with hearing or vision loss may characteristically tilt the head in an awkward position to hear or see better. A child with feelings of self-worth usually has a straight, well balanced posture, and has feelings of security.

The nurse is assessing the functional self-care level of a child and determines that the child requires the assistance of a caregiver for general hygiene and dressing. How would the nurse rate the child? 1. 0 2. I 3. II 4. IV

3 The nurse should rate the child as a II (two) because the child requires assistance of a caregiver for general hygiene and dressing. A grading of 0 (zero) is given to the child who is capable of taking full self-care. A grading of a I (one) is given to the child who requires the use of equipment or a device for self-care. A child who is totally dependent and does not participate in self-care would be rated a IV (four).

The nurse is caring for a child with an influenza viral infection. The child is anxious because the parents are unable to stay with the child. What should the nurse do to relieve the child's anxiety? The nurse should: 1 Not maintain any eye contact with the child. 2 Not speak with the child about missing the parents. 3 Use the phone to let the child talk with the parents. 4 Use a laptop to allow the child and parents to talk

3 The nurse should use a telephone to maintain contact between the child and parents so that the child can feel comfortable. It helps relieve the child's anxiety. The nurse should maintain eye contact and gently touch the child to establish rapport. The nurse should talk with the child about the parents and family to prevent detachment of the child from the parents. The nurse should not use a laptop to contact the child and parents. The laptop may not be compatible with medical equipment, and use may be restricted in certain areas.

The nurse is assessing the cranial nerve function in a child. The nurse asks the child to look down and in. Which cranial nerve is the nurse assessing? 1 Optic nerve 2 Trochlear nerve 3 Trigeminal nerve 4 Oculomotor nerve

3 When a child looks down and in, the eye moves down and out. This assesses the superior oblique muscle and the trochlear nerve. Optic nerve assessment is done through checking the perception of light, visual acuity, and peripheral vision. The trigeminal nerve is assessing the sensory perception of the face as well as the scalp, nasal and buccal mucosa. The nurse would also ask the child to bite down, open their jaw, and close their eyes to test for symmetry and strength. The oculomotor nerve is assessed by asking the child to follow the object shown by the nurse or moving a penlight in the six cardinal positions of gaze.

The nurse is assessing the heart sounds of a child and decides that the child needs further evaluation. What could be the reason for seeking further evaluation? 1 Auscultation of an S1 heart sound 2 Auscultation of an S3 heart sound 3 Presence of S1 and S2 heart sounds 4 Presence of S3 and S4 heart sounds

4 Abnormal heart sounds are called murmurs. These sounds are produced by vibrations within the heart chambers or the back flow of blood in major arteries. If S3 and S4 heart sounds are heard, further evaluation would be needed to detect any abnormalities. S3 heart sounds are normally heard in children but they don't require any further evaluation. S1 and S2 heart sounds are normal heart sounds. Closure of the tricuspid and mitral valves produces S1 sounds, and closure of the pulmonic and aortic valve produces S2 sounds. These sounds provide important auditory data required for assessing the heart.

Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? 1 Palpating another area simultaneously 2 Asking the child not to laugh or move if it tickles 3 Beginning with deeper palpation and gradually progressing to superficial palpation 4 Having the child "help" with palpation by placing his or her hand over the palpating hand

4 Having the child help with palpation allows the nurse to perform the assessment while including the child in the care. Palpating another area simultaneously does not promote relaxation and makes it more difficult to perform the abdominal assessment. Asking the child not to laugh may only contribute to the child's laughter or may prove frustrating to both the child and the nurse. Deeper palpation enhances the "tickling" sensation instead of lessening it.

A child is hospitalized for a chronic illness. Initially, the child showed symptoms of depression but later started interacting with others. What does the nurse infer from the patient's behavior? The child is: 1 Content with the care provided. 2 Showing improved social skills. 3 Getting used to the surroundings. 4 Detached from both parents.

4 Hospitalized children undergo depression when they are separated from their parents. As they go through the stages of separation anxiety, children eventually detach from their parents and develop new and shallow relationships. Children interact with others and develop new relationships as a result of resignation, not contentment. Children who are detached begin to show increased interest in their surroundings. They are also not developing their social interaction skills. Children try not to think about the separation; hence, they start developing new interactions.

The nurse measures and documents the vital signs of an adolescent. If the pulse is graded as +1, what are the characteristics of the pulse? The pulse is: 1 strong, bounding, and is not obliterated with pressure 2 difficult to palpate and may be obliterated with pressure 3 easy to palpate and not easily obliterated with pressure 4 hard to feel, thready, and easily obliterated with pressure

4 If the pulse is graded as +1, the pulse is difficult to palpate, thready, weak, and easily obliterated with pressure. If the pulse is strong, bounded, and not obliterated with pressure, the grade is +4. If the pulse is difficult to palpate and may be obliterated with pressure, then it is graded with a +2. If the pulse is easy to palpate and not easily obliterated with pressure, then the grade is +1.

Which statement explains why it can be difficult to assess a child's dietary intake? 1 No systematic assessment tool has been developed for this purpose. 2 Biochemical analysis for assessing nutrition is expensive. 3 Families usually do not understand much about nutrition. 4 Recall of children's food consumption is frequently unreliable.

4 It is difficult for parents to recall exactly what their child has eaten . Concurrent food diaries are somewhat more reliable. Systematic tools have been developed and are available. Nutrients for different foods are known; it is the quantity and type of food consumed that are difficult to ascertain. The family does not need nutrition knowledge to describe what the child has eaten.

The nurse is assessing skin turgor in a child. The nurse grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended, or tented, for a few seconds, then slowly falls back on the abdomen. Which evaluation can the nurse correctly assume? 1 The tissue shows normal elasticity. 2 The child is properly hydrated. 3 The assessment is done incorrectly. 4 The child has poor skin turgor.

4 Tenting is the term for poor skin turgor. In normal elasticity the skin returns immediately to its original position. If the child is properly hydrated, skin turgor is elastic. The assessment was done correctly.

In what position does the nurse place the child while examining the genitalia of a 13-month-old female child? 1 Fowler position 2 Reclined position 3 Standing position 4 Semi-reclining position

4 The convenient position for the examination of the genitalia involves placing the child in a semi-reclining position on a parent's lap, with the feet supported on the nurse's knees. The examination of female genitalia is limited to inspection and palpation of external structures. If the nurse places a child in Fowler position, the nurse may not be able to fully assess the genitalia. In the reclined position, the nurse cannot inspect or palpate the genitalia. At 13 months, the child is unable to stand independently. Inspection can be done in this position, but palpation is not possible.

The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is to: 1 use the small cuff. 2 use the large cuff. 3 use either cuff, using palpation method. 4 locate the proper size cuff before taking the blood pressure.

4 To obtain an accurate blood pressure reading, it is preferable to use the proper-size cuff. Locating one before taking the blood pressure is the best nursing action. The smaller cuff gives a falsely increased blood pressure and is not the method of choice. The larger cuff (which may give a falsely lowered blood pressure) is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice. Auscultation is preferred to palpation.

Following the assessment of the child, the nurse documents normal vesicular breath sounds. How does the nurse categorize vesicular breath sounds as normal? 1 The inspiratory phase is shorter than the expiratory phase. 2 The inspiratory phase is longer than the expiratory phase. 3 Expiration is louder, longer, and higher pitched than inspiration. 4 Inspiration is louder, longer, and higher pitched than expiration.

4 Vesicular breath sounds can be heard over the entire surface of the lungs, with the exception of the upper intrascapular area and area beneath the manubrium. These sounds are characterized based on the variation between inspiration and expiration. Inspiration is louder, longer, and higher pitched than expiration. Shorter inspiratory sounds and longer expiratory sounds are characteristic of bronchial sounds and heard only over the trachea. If the inspiratory phase is louder and longer than expiration, this may signal a pulmonary obstruction or respiratory problems not normally found in children.

The nurse is observing the respiratory pattern of a child who is crying. The nurse documents that the child has an increased rate and depth of respirations due to crying. What term does the nurse use to describe this? 1 Dyspnea 2 Hyperpnea 3 Hypoventilation 4 Hyperventilation

4 When a child cries, oxygen intake is decreased due to the increased rate and depth of respirations. Alveolar carbon dioxide concentration is higher than body production and it results in hyperventilation. Hyperventilation may be voluntary or involuntary. Dyspnea is distress during breathing or an inadequate breathing pattern due to pathological illness. Dyspnea can also be caused by a respiratory and cardiovascular problem. During times of exercise or after heavy activities, the respiratory pattern that is needed to meet the metabolic demands is termed as hyperpnea. In situations where there is inadequate oxygenation, the pattern of respiration is considered hypoventilation. If it exceeds the limits it may also cause respiratory acidosis.

In which order does the nurse take the history of the child who presents with a temperature of 102° F (38.8° C)? 1. Child's past medical history 2. Present illness of the child 3. Chief complaints of the child 4. Child's family medical history 5. Child's nutritional assessment 6. Determining the child's identity

6, 3, 2, 1, 4, 5 The first step in the history-taking process is to identify the person. Then move on to the child's chief complaints. This will determine the reason for the child and parents seeking professional health attention. The child's present illness helps to obtain all the details related to the chief complaints and to plan care accordingly. Past medical history of the child elicits information about previous illnesses or health conditions of which the health care team needs to be aware. The family medical history elicits the role of any genetic diseases and familial tendencies, as well as to assess exposure to communicable diseases. Dietary intake and clinical examination of the nutritional status of a child elicit the adequacy and requirements of the child's nutritional needs.

Fluid and Electrolyte Alteration 1. Bodily fluids are composed of two elements: water and _____.

ANS: Solutes Water is the primary constituent of bodily fluids. An infant's weight is approximately 75% water compared to the adult's weight, which is 55% to 60% water. Solutes are composed of both electrolytes and nonelectrolytes. The body's solutes include sodium, potassium, chloride, calcium, and magnesium.

6. What is the best response for a nurse to make to a parent who has asked, "When should I start dental care for my child?" a. "The recommendation is for children to have a dental examination no later than 2.5 years." b. "Children should see a dentist at least one time before kindergarten." c. "The recommendation is for children to have a dental examination before first grade." d. "A dental examination by 1 year of age is the current recommendation."

ANS: A Feedback A Children should be examined by a dentist between the time the first teeth erupt and primary dentition is complete at 2.5 years of age. B Children require regular dental examinations well before kindergarten. C Six years of age is too late to begin regular dental examinations. D Children should be examined by a dentist between the time the first teeth erupt and the time primary dentition is complete at 2.5 years of age.

8. The nurse knows that measuring temperature is an integral part of assessment. Which concept is important for the nurse to know when taking a child's temperature? a. The method used should be consistent. b. Rectal temperatures should always be taken on infants. c. Oral temperatures can be taken on all children older than 5 years of age. d. Axillary temperatures should be taken at night.

ANS: A Feedback A The method that is determined most appropriate for the child should be used consistently—the same site and device to maintain consistency and allow reliable comparison and tracking of temperatures over time. B Because of the risk of rectal perforation and the intrusive nature of the procedure, rectal temperatures are measured only when no other route can be used or when it is necessary to obtain a core body temperature. C Oral temperatures can be used on most children older than 6 years of age but may be inaccurate because of oral intake, oral surgery, oxygen therapy, nebulizer treatments, or crying. D The method of measuring temperature should be consistent, including at night.

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

ANS: A Feedback A The parents' preferences for assisting, observing, or waiting outside the room should be assessed as well as the child's preference for parental presence. The child's choice should be respected. B If the mother and child are agreeable, then the mother is welcome to stay. C An appropriate substitute for the mother is necessary only if the mother does not wish to stay. D Support is offered to the child regardless of parental presence.

13. What is appropriate to include in the care plan for a family of a child with a tracheostomy? a. Suction of the tracheostomy every 2 to 4 hours or as needed b. Application of powder around the stoma to decrease irritation c. Suction catheter insertion limited to less than 30 seconds d. Hygiene that includes showers, not baths

ANS: A Feedback A To maintain a patent airway in a child with a tracheostomy, assessing respiratory status and suctioning every 2 to 4 hours or as needed using Standard Precautions is an important intervention to teach families. B Talc powder should be avoided because of the risk of inhalation injury from breathing the powder particles. C Catheter insertion for suctioning should be less than 5 seconds to prevent hypoxia. D The family should be taught to avoid getting water in the tracheostomy during bath time. Showers should be discouraged.

Fluid and Electrolyte Alteration 12. Which diet would the nurse recommend to the mother of a child who is having mild diarrhea? a. Rice, potatoes, yogurt, cereal, and cooked carrots b. Bananas, rice, applesauce, and toast c. Apple juice, hamburger, and salad d. Whatever the child would like to eat

ANS: A Bland but nutritious foods including complex carbohydrates (rice, wheat, potatoes, cereals), yogurt, cooked vegetables, and lean meats are recommended to prevent dehydration and hasten recovery. Bananas, rice, applesauce, and toast used to be recommended for diarrhea (BRAT diet). These foods are easily tolerated, but the BRAT diet is low in energy, density, fat, and protein. Fatty foods, spicy foods, and foods high in simple sugars should be avoided. The child should be offered foods he or she likes but should not be encouraged to eat fatty foods, spicy foods, and foods high in simple sugars.

Fluid and Electrolyte Alteration 11. What is the best response for the nurse to give a parent about contacting the physician regarding an infant with diarrhea? a. "Call your pediatrician if the infant has not had a wet diaper for 6 hours." b. "The pediatrician should be contacted if the infant has two loose stools in an 8-hour period." c. "Call the doctor immediately if the infant has a temperature greater than 100° F." d. "Notify the pediatrician if the infant naps more than 2 hours."

ANS: A No urine output in 6 hours needs to be reported because it indicates dehydration. Two loose stools in 8 hours is not a serious concern. If blood is obvious in the stool or the frequency increases to one bowel movement every hour for more than 8 hours, the physician should be notified. A fever greater than 101° F should be reported to the infant's physician. It is normal for the infant who is not ill to nap for 2 hours. The infant who is ill may nap longer than the typical amount.

What should the nurse include in a teaching plan for the parents of a child with vesicoureteral reflux? a. The importance of taking prophylactic antibiotics if prescribed b. Suggestions for how to maintain fluid restrictions c. The use of bubble baths as an incentive to increase bath time d. The need for the child to hold urine for 6 to 8 hours

ANS: A Prophylactic antibiotics are sometimes used to prevent urinary infection in a child with vesicoureteral reflux, especially if they are waiting for the results of imaging studies or have recurrent UTIs. If prescribed, the parents should be taught that the child must finish the entire course of antibiotics to prevent bacterial resistance. Fluids are not restricted when a child has vesicoureteral reflux. In fact, fluid intake should be increased as a measure to prevent UTIs. Bubble baths should be avoided to prevent urethral irritation and possible UTI. To prevent UTIs, the child should be taught to void frequently and never resist the urge to urinate. PTS: 1 DIF: Cognitive Level: Application/Applying

Fluid and Electrolyte Alteration 1. The parents of a child with acid-base imbalance ask the nurse about mechanisms that regulate acid-base balance. Which statement by the nurse accurately explains the mechanisms regulating acid-base balance in children? a. The respiratory, renal, and chemical-buffering systems b. The kidneys balance acid; the lungs balance base. c. The cardiovascular and integumentary systems d. The skin, kidney, and endocrine systems

ANS: A The acid-base system is regulated by chemical buffering, respiratory control of carbon dioxide, and renal regulation of bicarbonate and secretion of hydrogen ions. Both the kidneys and the lungs, along with the buffering system, contribute to acid-base balance. Neither system regulates acid or base balances exclusively. The cardiovascular and integumentary systems are not part of acid-base regulation in the body. Chemical buffers, the lungs, and the kidneys work together to keep the blood pH within normal range.

Fluid and Electrolyte Alteration 10. Which action is the primary concern in the treatment plan for a child with persistent vomiting? a. Detecting the cause of vomiting b. Preventing metabolic acidosis c. Positioning the child to prevent further vomiting d. Recording intake and output

ANS: A The primary focus of managing vomiting is detection of the cause and then treatment of the cause. Metabolic alkalosis results from persistent vomiting. Prevention of complications is the secondary focus of treatment. The child with persistent vomiting should be positioned upright or side-lying to prevent aspiration. Recording intake and output is a nursing intervention, but it is not the primary focus of treatment.

Fluid and Electrolyte Alteration 1. Which assessment findings indicate to the nurse that a child has excess fluid volume? (Select all that apply.) a. Weight gain b. Decreased blood pressure c. Moist breath sounds d. Poor skin turgor e. Rapid bounding pulse

ANS: A, C, E A child with fluid volume excess will have a weight gain, moist breath sounds due to the excess fluid in the pulmonary system, and a rapid bounding pulse. Other signs seen with fluid volume excess are increased blood pressure, edema, and fatigue. Decreased blood pressure and poor skin turgor are signs of fluid volume deficit.

14. Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler? a. Measuring oral temperature for 5 minutes b. Counting apical heart rate for 60 seconds c. Observing chest movement for respiratory rate d. Recording blood pressure as P/80

ANS: B Feedback A A child younger than 6 years may not be able to hold a thermometer under the tongue. B Apical pulse measurement when the child is quiet for 1 full minute is the preferred method for measuring vital signs in infants and children ages 2 years and younger. C The respiratory rate in infants and young children can be measured by watching abdominal movement. D It may be difficult to auscultate blood pressure in infants and toddlers. Systolic pressure can be palpated and should be recorded as systolic pressure over pulse (e.g., 80/P).

18. An important nursing consideration when performing a bladder catheterization on a young boy is to a. Use clean technique, not Standard Precautions. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

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

9. A parent calls the pediatrician's office because her 1-year-old child has a 100° F temperature. What is the most appropriate initial nursing response to make to the parent? a. "Did you feel your child's forehead?" b. "Tell me about the child's behavior." c. "Has anyone in your home been sick lately?" d. "There is no need for concern if the child's temperature is less than 101° F."

ANS: B Feedback A Feeling a child's forehead can give clues related to whether the child's temperature should be measured; if it has already been measured, this is unnecessary because it does not give accurate information about the child's body temperature. B In general, the height of the fever is not an indication of the seriousness of the illness. It is more important to note changes in the child's behavior. If a child has a low-grade temperature and acts sick, he or she should be assessed further. C This question will yield relevant information for the nurse to use in advising the parent, but it is not the best initial response. D Although the height of the temperature is not an indication of the seriousness of the child's illness, it is incorrect to tell a parent to be unconcerned about temperatures less than 101° F.

1. What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture? a. "You must hold still or I'll have someone hold you down. This is not going to hurt." b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less." c. "Be a big boy and hold still. This will be over in just a second." d. "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be over soon."

ANS: B Feedback A Honesty is always best and a venipuncture may hurt. B Honesty is the best approach. Children should be told what sensation they will feel during a procedure. A 5-year-old child should not be expected to hold still, and assistance ensures safety to everyone. C This statement is not supportive or honest. D Parents should be encouraged to remain with the child unless they are extremely uncomfortable doing so.

21. In preparing to give "enemas until clear" to a young child, the nurse should select a. Tap water b. Normal saline c. Oil retention d. Fleet solution

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

4. The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include a. Planning for a short teaching session of about 30 minutes b. Telling the child that procedures are never a form of punishment c. Keeping equipment out of the child's view d. Using correct scientific and medical terminology in explanations

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

11. What information should the nurse include in teaching parents how to care for a child's gastrostomy tube at home? a. Never turn the gastrostomy button. b. Clean around the insertion site daily with soap and water. c. Expect some leakage around the button. d. Remove the tube for cleaning once a week.

ANS: B Feedback A The gastrostomy button should be rotated in a full circle during cleaning. B The skin around the tube insertion site should be cleaned with soap and water once or twice daily. C Leakage around the tube should be reported to the physician. D A gastrostomy tube is placed surgically. It is not removed for cleaning.

12. Which nursing action is the most appropriate when applying a face mask to a child for oxygen therapy? a. The oxygen flow rate should be less than 6 L/min. b. Make sure the mask fits properly. c. Keep the child warm. d. Remove the mask for 5 minutes every hour.

ANS: B Feedback A The oxygen flow rate should be greater than 6 L/min to prevent rebreathing of exhaled carbon dioxide. B A properly fitting face mask is essential for adequate oxygen delivery. C Oxygen delivery through a face mask does not affect body temperature. D A face mask used for oxygen therapy is not routinely removed.

Fluid and Electrolyte Alteration 9. What is the best response by the nurse to a parent asking about antidiarrheal medication for her 18-month-old child? a. "It is okay to give antidiarrheal medication to a young child as long as you follow the directions on the box for correct dosage." b. "Antidiarrheal medication is not recommended for young children because it slows the body's attempt to rid itself of the pathogen." c. "I'm sure your child won't like the taste, so give extra fluids when you give the medication." d. "Antidiarrheal medication will lessen the frequency of stools, but give your child Gatorade to maintain electrolyte balance."

ANS: B Antidiarrheal medications may actually prolong diarrhea because the body will retain the organism causing the diarrhea, further increasing fluid and electrolyte losses. The use of these medications is not recommended for children younger than 2 years old because of their binding nature and potential for toxicity. Antidiarrheal medications are not recommended for children younger than 2 years old. This action is inappropriate because antidiarrheal medications should not be given to a child younger than 2 years old. It is not appropriate to advise a parent to use antidiarrheal medication for a child younger than 2 years old. Education about appropriate oral replacement fluids includes avoidance of sugary drinks, apple juice, sports beverages, and colas.

Which statement by a school-age girl indicates the need for further teaching about the prevention of urinary tract infections (UTIs)? a. "I always wear cotton underwear." b. "I really enjoy taking a bubble bath." c. "I go to the bathroom every 3 to 4 hours." d. "I drink four to six glasses of fluid every day."

ANS: B Bubble baths should be avoided because they tend to cause urethral irritation, which leads to UTI. It is desirable to wear cotton rather than nylon underwear. Nylon tends to hold in moisture and promote bacterial growth, whereas cotton absorbs moisture. Children should be encouraged to urinate at least four times a day. An adequate fluid intake prevents the buildup of bacteria in the bladder. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating

Fluid and Electrolyte Alteration 5. What is the most important factor in determining the rate of fluid replacement in the dehydrated child? a. The child's weight b. The type of dehydration c. Urine output d. Serum potassium level

ANS: B Isonatremic and hyponatremic dehydration resuscitation involves fluid replacement over 24 hours. Hypernatremic dehydration involves a slower replacement rate to prevent a sudden decrease in the sodium level. The child's weight determines the amount of fluid needed, not the rate of fluid replacement. One milliliter of body fluid is equal to 1 g of body weight; therefore a loss of 1 kg (2.2 lb) is equal to 1 L of fluid. Urine output is not a consideration for determining the rate of administration of replacement fluids. Potassium level is not as significant in determining the rate of fluid replacement as the type of dehydration.

A nurse is assessing lab results on four patients in the general pediatric unit. What child should the nurse go see first? a. Urine specific gravity: 1.025 b. Urine ketones: positive in large amounts c. Serum BUN 21 mg/dL d. Serum creatinine 0.7 mg/dL

ANS: B Ketones should not be present in the urine. When found, they are indicative of starvation, diabetic ketoacidosis, fever, prolonged vomiting, anorexia, and severe diarrhea. The nurse should see this child first. The other lab values are normal. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing

2. Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of immunosuppression? a. Spiritual distress b. Social isolation c. Deficient diversional activity d. Sleep deprivation

ANS: C Feedback A A 5-year-old child is not developmentally advanced enough to feel spiritual distress. B The main social system for a 5-year-old child is the family, who should be allowed liberal visitation. C Children in isolation need extra attention to avoid boredom. D Sleep deprivation may occur during hospitalization but is not specific to isolation.

15. Which action by the nurse is appropriate when preparing a child for a procedure? a. Discourage the child from crying during the procedure. b. Use professional terms so the child will understand what is happening. c. Give the child choices whenever possible. d. Discourage the parents from staying in the room during the procedure.

ANS: C Feedback A Children (and adults) should be given permission to cry. B Age-appropriate language should always be used. C Allowing children to make choices gives them a sense of control. D Parents should be encouraged to stay in the room and give support to the child.

5. Which nursing action is most appropriate when treating a child who has a fever of 102.5° F? a. Restrict fluid intake. b. Administer an aspirin. c. Administer an antipyretic such as acetaminophen. d. Bathe the child in tepid water.

ANS: C Feedback A Dehydration can occur from insensible water loss. Offer the child fluids frequently and evaluate the need for IV therapy. B Aspirin is avoided because of the potential association with Reye's syndrome. C Treatment of a fever can include administration of an antipyretic. D A sponge or tub bath with tepid water to reduce fever can cause shivering and ultimately increase the child's temperature.

7. Which action is appropriate to promote a toddler's nutrition during hospitalization? a. Allow the child to walk around during meals. b. Require the child to empty his or her plate. c. Ask the child's parents to bring a cup and utensils from home. d. Select new foods for the child from the menu.

ANS: C Feedback A For safety reasons, "roaming" while eating should not be permitted. The child should be seated during meals. B Toddlers often use food as a source of control. Forcing a toddler to eat only increases the child's sense of powerlessness. Toddlers also experience food jags, a normal phenomenon when they will only eat certain foods. C Using familiar items during mealtimes increases the toddler's sense of security and control. D Hospitalization is a stressful experience for the toddler. It is not the time to introduce the child to new foods.

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

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

10. What nursing action is appropriate for specimen collection? a. Follow sterile technique for specimen collection. b. Sterile gloves are worn if the nurse plans to touch the specimen. c. Use Standard Precautions when handling body fluids. d. Avoid wearing gloves in front of the child and family.

ANS: C Feedback A Specimen collection is not always a sterile procedure. B Gloves should be worn if there is a chance the nurse will be contaminated. The choice of sterile or clean gloves will vary according to the procedure or specimen. C Standard Precautions should always be used when handling body fluids. D The child and family should be educated in the purpose of glove use, including the fact that gloves are used with every patient, so that they will not be offended or frightened.

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

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

17. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should a. Wash hands thoroughly. b. Check the gloves for leaks. c. Use an alcohol-based hand rub. d. Apply new gloves before touching the next patient.

ANS: C Feedback A When gloves are worn, the hands can be cleaned using an alcohol-based hand rub. If hands are visibly soiled they should be washed with soap and water. B Gloves should be disposed of after use. C Evidence-based research has demonstrated that alcohol-based rubs are more effective for eliminating organisms. D Hands should be thoroughly cleaned before new gloves are applied.

Fluid and Electrolyte Alteration 4. Which assessment is most relevant to the care of an infant with dehydration? a. Temperature, heart rate, and blood pressure b. Respiratory rate, oxygen saturation, and lung sounds c. Heart rate, sensorium, and skin color d. Diet tolerance, bowel function, and abdominal girth

ANS: C Changes in heart rate, sensorium, and skin color are early indicators of impending shock in the child. Children can compensate and maintain an adequate cardiac output when they are hypovolemic. Blood pressure is not as reliable an indicator of shock as are changes in heart rate, sensorium, and skin color. Respiratory assessments will not provide data about impending hypovolemic shock. Diet tolerance, bowel function, and abdominal girth are not as important indicators of shock as heart rate, sensorium, and skin color.

Fluid and Electrolyte Alteration 7. What assessment should the nurse make before initiating an intravenous (IV) infusion of dextrose 5% in 0.9% normal saline solution with 10 mEq of potassium chloride for a child hospitalized with dehydration? a. Fluid intake b. Number of stools c. Urine output d. Capillary refill

ANS: C Potassium chloride should never be added to an IV solution in the presence of oliguria or anuria (urine output less than 0.5 mL/kg/hr). Fluid intake does not give information about renal function. Stool count sheds light on intestinal function. Renal function is the concern before potassium chloride is added to an IV solution. Assessment of capillary refill does not provide data about renal function.

Which statement by a parent of a child with nephrotic syndrome indicates an understanding of a no-added-salt diet? a. "I can give my child sweet pickles." b. "My child can put ketchup on his hotdog." c. "I can let my child have potato chips." d. "I do not put any salt in foods when I am cooking."

ANS: D A no-added-salt diet means that no salt should be added to foods, either when cooking or before eating. Pickles of any type, hotdogs, and potato chips are all prohibited on this diet. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating

Fluid and Electrolyte Alteration 2. A child has a 2-day history of vomiting and diarrhea. He has hypoactive bowel sounds and an irregular pulse. Electrolyte values are sodium, 139 mEq/L; potassium, 3.3 mEq/L; and calcium, 9.5 mg/dL. This child is likely to have which of the following electrolyte imbalances? a. Hyponatremia b. Hypocalcemia c. Hyperkalemia d. Hypokalemia

ANS: D A serum potassium level less than 3.5 mEq/L is considered hypokalemia. Clinical manifestations of hypokalemia include muscle weakness, decreased bowel sounds, cardiac irregularities, hypotension, and fatigue. The normal serum sodium level is 135 to 145 mEq/L. A level of 139 mEq/L is within normal limits. A serum calcium level less than 8.5 mg/dL is considered hypocalcemia. A serum potassium level greater than 5 mEq/L is considered hyperkalemia.

Fluid and Electrolyte Alteration 8. A nurse is teaching parents about diarrhea. Which statement by the parents indicates understanding of the teaching? a. Diarrhea results from a fluid deficit in the small intestine. b. Organisms destroy intestinal mucosal cells, resulting in an increased intestinal surface area. c. Malabsorption results in metabolic alkalosis. d. Increased motility results in impaired absorption of fluid and nutrients.

ANS: D Increased motility and rapid emptying of the intestines result in impaired absorption of nutrients and water. Electrolytes are drawn from the extracellular space into stool, and dehydration results. Diarrhea results from fluid excess in the small intestine. Destroyed intestinal mucosal cells result in decreased intestinal surface area. Loss of electrolytes in the stool from diarrhea results in metabolic acidosis.

Fluid and Electrolyte Alteration 3. Which statement best describes why infants are at greater risk for dehydration than older children? a. Infants have an increased ability to concentrate urine. b. Infants have a greater volume of intracellular fluid. c. Infants have a smaller body surface area. d. Infants have an increased extracellular fluid volume.

ANS: D The larger ratio of extracellular fluid to intracellular fluid predisposes the infant to dehydration. Because the kidneys are immature in early infancy, there is a decreased ability to concentrate the urine. Infants have a larger proportion of fluid in the extracellular space. Infants have proportionately greater body surface area in relation to body mass, which creates the potential for greater fluid loss through the skin and gastrointestinal tract.

Fluid and Electrolyte Alteration 6. What is the priority nursing intervention for a 6-month-old infant hospitalized with diarrhea and dehydration? a. Estimating insensible fluid loss b. Collecting urine for culture and sensitivity c. Palpating the posterior fontanel d. Measuring the infant's weight

ANS: D Weight is a crucial indicator of fluid status. It is an important criterion for assessing hydration status and response to fluid replacement. Infants have a greater total body surface area and therefore a greater potential for fluid loss through the skin. It is not possible to measure insensible fluid loss. Urine for culture and sensitivity is not usually part of the treatment plan for the infant who is dehydrated from diarrhea. The posterior fontanel closes by 2 months of age. The anterior fontanel can be palpated during an assessment of an infant with dehydration.

1. The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required? Select all that apply. a. Catheterized urine collection b. IV line insertion c. Oxygen administration d. Lumbar puncture e. CT scan with contrast

ANS: D, E Feedback Correct Informed consent is required for invasive procedures that involve risk to a child, such as a lumbar puncture, chest tube insertion, and bone marrow aspirations. A consent is also required for a CT scan with contrast. Incorrect Informed consent is not required for procedures that are covered under the general consent to treat that is signed at admission by a parent or a guardian. These procedures all fall under this category.

2. The nurse is caring for a 2-year-old patient admitted with suspected respiratory syncytial virus (RSV). The nurse anticipates that the provider will order a throat culture to confirm the diagnosis. Is this statement true or false?

ANS: F A sputum specimen is necessary to rule out other diagnoses such as influenza or pneumonia. Because younger children can seldom produce a deep cough on command and often swallow secretions, obtaining specimens often requires nasal washing. Throat cultures are used to identify the causative agents for either a sore throat or tonsillitis.

1. The nurse is admitting a preschooler to the hospital for a scheduled minor surgical procedure requiring an overnight stay. Since the patient is under the age of 12 years, a fall risk assessment is unnecessary. Is this statement true or false?

ANS: F Most hospitalized children are physically active and may be at risk for injury from falls. Factors that contribute to falls include an altered mental status, the need for mobility assistance, and lack of attentiveness on the part of the parent. It is recommended that all children undergo a fall risk screening when admitted to a hospital and again if motor or sensory changes occur.

Fluid and Electrolyte Alteration 1. The nurse who provides care for young children with fluid and electrolyte imbalance understands that they are more vulnerable to changes in fluid balance than adults. Under normal conditions the amount of fluid ingested during the day should equal the amount of fluid lost. Sensible water loss is that which occurs through the respiratory tract and skin. Is this statement true or false?

ANS: F Sensible water loss occurs through urine output. Insensible water loss occurs through the skin and respiratory tract. Insensible water loss per unit of body weight is significantly higher in infants and young children due to the faster respiratory rate and higher evaporative water losses.

Fluid and Electrolyte Alteration 2. Alterations in acid-base balance can affect cellular metabolism and enzymatic processes. When alterations in pH become too much for buffer systems to handle, compensatory mechanisms are activated. If the pH drops below normal, then acidosis will occur. Is this statement true or false?

ANS: T Acidosis is the result of a drop in blood pH. The respiratory rate and depth will increase, removing carbon dioxide and raising blood pH. Conversely, in the presence of alkalosis, respiratory rate and depth decrease, lowering blood pH.