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9. At which developmental period do children have the most difficulty coping with death, particularly if it is their own? a. Toddlerhood b. Preschool c. School age d. Adolescence

D Adolescents, because of their mature understanding of death, remnants of guilt and shame, and issues with deviations from normal, have the most difficulty coping with death. Toddlers and preschoolers are too young to have difficulty coping with their own death. They fear separation from their parents. School-age children fear the unknown such as the consequences of the illness and the threat to their sense of security.

19. When is an autopsy required? a. In the case of a suspected suicide b. When a person has a known terminal illness c. With a hospice patient who dies at home d. With the victim of a motor vehicle collision

A Autopsy is usually required in cases of unexplained death, violent death, or suspected suicide. In other instances it may be optional, and parents should be informed. The cause of death is not unknown in a person with a known terminal illness, a hospice patient at home, or a victim of a motor vehicle collision. Autopsy can be requested by family, but it is not required.

2. Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group? a. No hurt. b. Red pain. c. Zero hurt. d. Least pain.

A No hurt is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. Least pain is less concrete than no hurt.

18. The nurse is often the individual who is in the optimum position to suggest tissue donation to a family (after consultation with the practitioner). What will occur if a family chooses organ or tissue donation? a. The funeral will be delayed. b. Cremation is the preferred method of burial. c. Written consent is required for tissue or organ donation. d. An open casket cannot be used subsequent to this procedure.

C about:blank 142/225 Organ and tissue donation cannot proceed without the familys written informed consent. There is usually no delay in the funeral. Organs are usually retrieved before actual death, and tissue must be removed soon after. No obvious disfigurement of the body occurs, and an open casket can be used for the funeral.

12. What is a significant common side effect that occurs with opioid administration? a. Euphoria b. Diuresis c. Constipation d. Allergic reactions

C about:blank 37/225 Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.

19. A burn patient is experiencing anxiety over dressing changes. Which prescription should the nurse expect to be ordered to control anxiety? a. Lorazepam (Ativan) b. Oxycodone (OxyContin) c.Fentanyl (Sublimaze) d. Morphine Sulfate (Morphine)

A A benzodiazepine such as lorazepam is prescribed as an antianxiety agent. Oxycodone, fentanyl, and morphine sulfate are opioid analgesics.

11. The family and child have decided that hospice care best meets their needs during the terminal phase of illness. The nurse recognizes that the parents understand the principles of this care when they make which statement? a. It will be good to be at home and care for our child. b. What a relief it will be not to need any more medicines. c. We are going to miss the support of the hospice team when our child dies. d. We know that once hospice care starts, we will not be able to return to the hospital if the care is difficult.

A A major principle of hospice care is that the family members are the principal caregivers and are supported by a team of professionals. Pain and symptom management is a priority. The family and visiting nurses administer medications to keep the child as pain and symptom free as possible. The hospice team provides bereavement support to help the family in the postdeath adjustment. This may last for up to a year or more. If the family decides they can no longer care for the child at home, readmission to a freestanding hospice or hospital is possible.

18. Which is a complication that can occur after abdominal surgery if pain is not managed? a. Atelectasis b. Hypoglycemia c. Decrease in heart rate d. Increase in cardiac output

A Pain associated with surgery in the abdominal region (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications such as pneumonia and atelectasis is high. Severe postoperative pain also results in sympathetic overactivity, which leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. Hypoglycemia, decreases in heart rate, and increases in cardiac output are not complications of poor pain management.

8. What statement is most descriptive of a school-age childs reaction to death? a. Very interested in funerals and burials b. Little understanding of words such as forever c. Imagine the deceased person to be still alive d. Can explain death from a religious or spiritual point of view

A School-age children are interested in naturalistic and physiologic explanations of why death occurs and what happens to the body. School-age children do have an established concept of forever and have a deeper understanding of death in a concrete manner. Adolescents may explain death from a religious or spiritual point of view.

13. The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first? a. Administer naloxone (Narcan). b. Discontinue the IV infusion. c. Discontinue morphine until the child is fully awake. d. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

A The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.

4. A 12-year-old child has failed several courses of chemotherapy. An experimental drug is available that his parents want him to receive. He has told his parents and the oncologists that he is ready to die and does not want any more chemotherapy. The nurse recognizes what to be true? a. Parents and child both need support in the decision making. b. Twelve-year-olds are minors and cannot give consent or refuse treatments. about:blank 137/225 c. The oncologists needs to make the decision because the parents and child disagree. d. The parents have the right and responsibility to make decisions for their children younger than age 18 years.

A This is a family issue that requires support to help both parents and child resolve the conflict. Because the child has little chance of survival, many institutions support the childs right to refuse or assent to therapy. The institution can obtain a court order to support the childs decision if verified by the oncologists. Twelve-year-olds can give consent for therapy under certain conditions, including being an emancipated minor and receiving therapy for birth control and sexually transmitted infections. Right to self-determination is also accepted if the child is fully aware of the consequences of the actions. The practitioners cannot take the responsibility for decision making from the parent or child. Parents have the responsibility for decision making, but certain circumstances do limit their authority.

14. What nursing intervention is most appropriate when providing comfort and support for a child when death is imminent? a. Limit care to essentials. b. Avoid playing music near the child. c. Whisper to the child instead of using a normal voice. d. Explain to the child the need for constant measurement of vital signs.

A When death is imminent, care should be limited to interventions for palliative care. Music may be used to provide comfort to the child. The nurse should speak to the child in a clear, distinct voice. Vital signs do not need to be measured frequently.

11. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which? a. Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure. b. Use a combination of fentanyl and midazolam for conscious sedation. c. Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure. d. Apply a transdermal fentanyl (Duragesic) patch immediately before the procedure.

B A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.

16. The nurse is making a home visit 48 hours after the death of an infant from sudden infant death syndrome (SIDS). What intervention is an appropriate objective for this visit? a. Give contraceptive information. b. Provide information on the grief process. c. Reassure parents that SIDS is not likely to occur again. d. Thoroughly investigate the home situation to verify SIDS as the cause of death.

B A home visit after the death of an infant is an excellent time to help the parents with the grief process. The nurse can clarify misconceptions about SIDS and provide information on support services and coping issues. Giving contraceptive information is inappropriate unless requested by parents. Telling the parents that SIDS is not likely to occur again is a false reassurance to the family. Investigating the home situation to verify SIDS as the cause of death is not the nurses role; this would have been done by legal and social services if there were a question about the infants death.

20. The nurse is providing support to a family that is experiencing anticipatory grief related to their childs imminent death. What statement by the nurse is therapeutic? a. Your other children need you to be strong. b. You have been through a very tough time. c. His suffering is over; you should be happy. d. God never gives us more than we can handle.

B Acknowledging that the family has been through a very tough time validates the loss that the parents have experienced. It is nonjudgmental. After the death of a child, the parent recognizes the responsibilities to the rest of the family but needs to be able to experience the grief of the loss. Telling the parents what they should do is giving advice. The parent would not be happy that the child has died, and stating so is argumentative. The parents may be angry with God, or their religious beliefs may be unknown, so the nurse should not provide false reassurance by talking to them about God.

20. A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety? a. Lorazepam (Ativan) b. Gabapentin (Neurontin) c. Hydromorphone (Dilaudid) d. Morphine sulfate (MS Contin)

B Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.

1. Which is the most consistent and commonly used data for assessment of pain in infants? a. Self-report b. Behavioral c. Physiologic d. Parental report

B Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to about:blank 33/225 self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

9. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurses response should be based on which characteristic about preterm infants pain? a. They may react to painful stimuli but are unable to remember the pain experience. b. They perceive and react to pain in much the same manner as children and adults. c. They do not have the cortical and subcortical centers that are needed for pain perception. d. They lack neurochemical systems associated with pain transmission and modulation.

B Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.

12. A child in the terminal stage of cancer has frequent breakthrough pain. Nonpharmacologic methods are not helpful, and the child is exceeding the maximum safe dose for opiate administration. What approach should the nurse implement? a. Add acetaminophen for the breakthrough pain. b. Titrate the opioid medications to control the childs pain as specified in the protocol. c. Notify the practitioner that immediate hospitalization is indicated for pain management. d. Help the parents and child understand that no additional medication can be given because of the risk of respiratory depression.

B The child on long-term opioid management can become tolerant to the drugs. Also, increasing amounts of drugs may be necessary for disease progression. It is important to recognize that there is no maximum dosage that can be given to control pain. Acetaminophen will offer little additional pain control; it is useful for mild and moderate pain. Immediate hospitalization is not necessary; increased dosages of pain medications can be administered in the home environment. about:blank 140/225 The principle of double effect allows for a positive interventionrelief of paineven if there is a foreseeable possibility that death may be hastened.

7. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine sulfate (Codeine) b. Morphine (Roxanol) about:blank 35/225 c. Methadone (Dolophine) d. Meperidine (Demerol)

B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief.

Chapter 19 1. What is a principle of palliative care that can be included in the care of children? a. Maintenance of curative therapy b. Child and family as the unit of care c. Exclusive focus on the spiritual issues the family faces d. Extensive use of opiates to ensure total pain control

B The principles of palliative care involve a multidisciplinary approach to the management of a terminal illness or the dying process that focuses on symptom control and support rather than on cure or life prolongation in the absence of the possibility of a cure. In pediatric palliative care, the focus of care is on the family. Palliative care requires the transition from curative to palliative care. The transition occurs when the likelihood of cure no longer exists. Spiritual issues are just one of the foci of palliative care. The multidisciplinary team focuses on physical, emotional, and about:blank 136/225 social issues as well. Pain control is a priority in palliative care. The use of opiates is balanced with the side effects caused by this class of drugs.

17. The nurse is teaching the parents of a child with recurrent headaches methods to modify behavior patterns that increase the risk of headache. Which statement by the parents indicates understanding the teaching? a. We will allow the child to miss school if a headache occurs. b. We will respond matter-of-factly to requests for special attention. c. We will be sure to give much attention to our child when a headache occurs. d. We will be sure our child doesnt have to perform at a band concert if a headache occurs.

B To modify behavior patterns that increase the risk of headache or reinforce headache activity, the nurse instructs the parents to avoid giving excessive attention to their childs headache and to respond matter-of-factly to pain behavior and requests for special attention. Parents learn to assess whether the child is avoiding school or social performance demands because of headache. about:blank 39/225

10. An 8-year-old girl has been uncooperative and angry since the diagnosis of cancer was made. Her parents tell the nurse that they do not know what to do because she is always so mad at us. What nursing action is most appropriate at this time? a. Explain to child that anger is not helpful. b. Help the parents deal with her anger constructively. c. Ask the parents to find out what she is angry about. about:blank 139/225 d. Encourage the parents to ignore the anger at this time.

B To school-age children, chronic illness and dying represent a loss of control. This threat to their sense of security and ego strength can be manifested by verbal uncooperativeness. The child can be viewed as impolite, insolent, and stubborn. The best intervention is to encourage children to talk about feelings and give control where possible. Verbal explanations would not be heard by the child. The child may not be cognizant of the anger. Ignoring the anger will not help the child gain some control over the events.

17. A critically injured child has died and is being removed from a ventilator in the pediatric intensive care unit. What is a priority nursing intervention for the family at this time? a. Ensure that parents are in the waiting room while the ventilator is removed. b. Help the parents understand that the child is already dead and no further interventions are necessary. c. Control the environment around the child and family to provide privacy. d. Encourage them to wait to see their child until the funeral home has prepared the body.

C Around the time of death, nursing care can be invaluable to the parents. The nurse should attempt to control the environment to ensure that the family and child have privacy. Other individuals such as clergy can be present if the family wishes. Attention to religious and cultural rituals may be important to them. The family should decide where they would like to be during removal from the ventilator. The family should be allowed to be with the child if they wish rather than waiting until the funeral home has prepared the body. Explain all interventions used for the child before death.

5. What explanation best describes how preschoolers react to the death of a loved one? a. Grief is acute but does not last long at this age. b. Children this age are too young to have a concept of death. c. Preschoolers may feel guilty and responsible for the death. d. They express grief in the same way that the adults in the preschoolers life are expressing grief.

C Because of egocentricity, the preschooler may feel guilty and responsible for the death. Preschoolers may need to distance themselves from the loss. Giggling or joking and regression to earlier behaviors may help them until they incorporate the loss. The preschoolers concept of death is more a special sleep or departure.

7. At which age do most children have an adult concept of death as being inevitable, universal, and irreversible? a. 4 to 5 years about:blank 138/225 b. 6 to 8 years c. 9 to 11 years d. 12 to 16 years

C By age 9 or 10 years, children have an adult concept of death. They realize that it is inevitable, universal, and irreversible. Preschoolers and young school-age children are too young to have an adult concept of death. Adolescents have a mature understanding of death.

8. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which? a. Give only an opioid analgesic at this time. b. Increase dosage of analgesic until the child is adequately sedated. c. Plan a preventive schedule of pain medication around the clock. d. Give the child a clock and explain when she or he can have pain medications.

C For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the childs attention on how long he or she will need to wait for pain relief.

15. The nurse is planning to administer a nonopioid for pain relief to a child. Which timing should the nurse plan so the nonopioid takes effect? a. 15 minutes until maximum effect b. 30 minutes until maximum effect c. 1 hour until maximum effect d. 1 1/2 hours until maximum effect

C Nonsteroidal antiinflammatory drugs (NSAIDs) can provide safe and effective pain relief when dosed at appropriate levels with adequate frequency. Most NSAIDs take about 1 hour for effect, so timing is crucial.

6. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include? a. The child will continue to sleep and be pain free. b. Parents cannot administer additional medication with the button. c. The pump can deliver baseline and bolus dosages. d. There is a high risk of overdose, so monitoring is done every 15 minutes.

C The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-yearold child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

3. A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should provide which explanation? a. This attitude is helpful to give parents time to cope. b. This will help the child cope effectively by denial. c. Terminally ill children know when they are seriously ill. d. Terminally ill children usually choose not to discuss the seriousness of their illness.

C The child needs honest and accurate information about the illness, treatments, and prognosis. Because of the increased attention of health professionals, children, even at a young age, realize that something is seriously wrong and that it involves them. Thus, denial is ineffective as a coping mechanism. The nurse should help parents understand the importance of honesty. Parents may need professional support and guidance from a nurse or social worker in this process. Children will usually tell others how much information they want about their condition.

6. A preschooler is found digging up a pet bird that was recently buried after it died. What is the best explanation for this behavior? a. He has a morbid preoccupation with death. b. He is looking to see if a ghost took it away. c. He needs reassurance that the pet has not gone somewhere else. d. The loss is not yet resolved, and professional counseling is needed.

C The preschooler can recognize that the pet has died but has difficulties with the permanence. Digging up the bird gives reassurance that the bird is still present. This is an expected response at this age. If the behavior persists, intervention may be required.

2. What factor is most important for parents implementing do not resuscitate (DNR) orders? a. Parents beliefs about euthanasia b. Presence of other children in the home c. Experiences of the health care team with other children in this situation d. Acknowledgment by health care team that child has no realistic chance for cure

D Earlier implementation of DNR orders, use of less aggressive therapies, and greater provision of palliative care measures are associated with an honest appraisal of the childs condition. Euthanasia involves an action carried out by a person other than the patient to end the life of the patient suffering from a terminal condition. DNR orders do not involve euthanasia but give permission for health care providers to allow the child to die without intervention. Parents state that regardless of the number of children they have, the death of a child is a new experience and nothing can prepare them for it. Health professionals may base their discussions with families on prior experiences, but families base their decision on an honest appraisal of their childs condition.

15. A 12-year-old boy is in the final phase of dying from leukemia. He tells the nurse who is giving him opiates for pain that his grandfather is waiting for him. How should the nurse interpret this situation? a. The boy is experiencing side effects of the opiates. b. The boy is making an attempt to comfort his parents. c. He is experiencing hallucinations resulting from brain anoxia. d. He is demonstrating readiness and acceptance that death is near.

D Near the time of death, many children experience visions of angels or people and talk with them. The children mention that they are not afraid and that someone is waiting for them. If the child has built a tolerance to the opioids, side effects are not likely. At this time, many children do begin to comfort their families and tell them that they are not afraid and are ready to die, but the visions usually precede this stage. There is no evidence of tissue hypoxia.

5. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain? a. Tactile stimulation b. Commercial warm packs c. Doing procedure during infant sleep d. Oral sucrose and nonnutritive sucking

D Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

about:blank 36/225 10. A preterm infant has just been admitted to the neonatal intensive care unit. The infants parents ask the nurse about anesthesia and analgesia when painful procedures are necessary. What should the nurses explanation be? a. Nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli. b. The risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief. c. Neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences. d. Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates.

D Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates.

16. The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route? a. Less expensive than oral medications b. Produces a first-pass effect through the liver c. Does not need to be administered frequently d. Provides most rapid onset of effect, usually in about 5 minutes

D The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the first-pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control.

13. A 7-year-old child is in the end stages of cancer. The parents ask you how they will know when death is imminent. What physical sign is indicative of approaching death? a. Hunger b. Tachycardia c. Increased thirst d. Difficulty swallowing

D The child begins to have difficulty swallowing as he or she approaches death. The childs appetite will decrease, and he or she will take only small bites of favorite foods or sips of fluids in the final few days. The pulse rate will slow.

14. The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching? a. With minimal sedation, the patients respiratory efforts are affected, and cognitive function is not impaired. b. With general anesthesia, the patients airway cannot be maintained, but cardiovascular function is maintained. c. During deep sedation, the patient can be easily aroused by loud verbal commands and tactile stimulation. d. During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation.

D When discussing levels of sedation, the participants should understand that during moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by painful stimuli; the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia, the patient loses about:blank 38/225 consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.