Ch 20-21

A nurse is assessing a 10-month-old baby's anterior fontanel and finds it slightly depressed; the fontanel measures 2 inches (5.08 cm). What conclusion and action are most appropriate?

Sign of dehydration; assess fluid status.

On physical assessment of the skin of a patient, the nurse documents cyanosis. What other related assessment should the nurse perform?

Take the child's vital signs, including blood pressure and pulse.

A nurse notes that when an infant is startled, she looks at her mother. What conclusion can the nurse make about this infant's development?

The infant can develop other relationships because he is secure.

A home health-care nurse sees several pediatric patients who have the nursing diagnosis of delayed growth and development. Which action by a child would indicate that outcomes have been met?

A 3-year-old child walks backward.

During a well-child visit, the pediatric nurse assesses a 2-year-old child for language development. Which developmental domain is the nurse assessing?

Cognitive

A nursing manager wants to decrease the amount of stress children have during hospitalization. What environmental change can the manager implement to best meet this goal?

Create a treatment room for procedures.

A nurse is providing anticipatory guidance to the parents of a 4-year-old disabled child. What nutritional information should the nurse provide?

Give child more than 70-90 kcal/kg/day.

A visiting nurse is making a home visit on a male 2-month-old child who was born prematurely. The nurse notes that the child has not been circumcised. What action by the nurse is most important?

Instruct parents not to retract the foreskin until after age 1.

A nurse is caring for a 5-year-old who broke his arm and is complaining of pain. What statement by the nurse to the child would be most helpful?

"You didn't do anything wrong that caused the hurt."

A mother has brought her 3-year-old child in to the clinic over concern about the child's lack of development in the last 3 months. Which information is the most appropriate for the nurse to provide to this mother?

Periods of growth and development are often followed by periods of rest.

A nurse reads in a child's chart that the child has pectus carinatum. What does the nurse understand this term to mean?

Protrusion of the chest

A nurse is working with a child at a nutrition site. The father is not in the child's life, and the mother has been in and out of jail, resulting in a series of caregivers for the child, who appears malnourished. Using Bandura's theory of growth and development, what should the nurse assess as a priority?

Self-esteem

A nurse is providing anticipatory guidance to the parents of a toddler. Which information is most important for the nurse to include regarding typical toddler behaviors?

Toddlers need constant supervision, because they don't understand what consequences can occur.

A nurse is explaining to a nursing student that a patient experienced a sentinel event during a previous hospitalization. What does the student understand about this event?

Unexpected event resulting in serious injury (or death)

A nurse is assessing a school-age child in the clinic with an earache and fever. Using the SODA mnemonic, what question by the nurse best relates to "S"?

"Does it keep you from sleeping?"

A middle-aged woman has brought a fussy baby to the pediatric clinic. After placing the woman and child in an exam room, which of the following questions should the nurse ask first?

"How are you related to the baby?"

A nurse is assessing a school-age child who complains of stomach aches after eating. Which question is appropriate for the "D" component of the OLD CAT mnemonic?

"How long does the pain last after you eat?"

The nurse is providing care to a newborn client and family during a well-baby checkup. Using Duvall's family development theory, which question is most appropriate for the nurse to ask?

"How old is your oldest child?"

A nurse is working at a community health-screening event. A woman tells the nurse that her oldest child is leaving home in a month and that this change is making her feel stressed and unneeded. What response by the nurse is the most appropriate?

"This is a great time to refocus on your marriage."

A mother brings her 1-year-old child to the pediatric clinic and appears frustrated and stressed. During the assessment, the mother states she tries to give her child exposure to new situations and people several times a week, but the outings always end with the child screaming and crying. Which response by the nurse is the most appropriate?

"Use an established routine and add new experiences slowly."

A mother and 1-year-old child are being seen in the well-child clinic. The mother asks the nurse for guidance in setting an appropriate bedtime for the child. She and her husband have tried several different times and can't seem to agree on the right time. Which response by the nurse is the most appropriate?

"What 'sleepy' behaviors does your child show when tired?"

A mother brings her child to the well-child clinic. She is distraught because the child tested well below normal on a school-administered intelligence (IQ) test. Which action by the nurse is the most appropriate?

Assess cultural background and economic status.

A nurse is weighing a 2-month-old infant in the clinic. To ensure safety, which action is most appropriate?

Place the baby in the scale and hold one hand just over the baby.

A child has had eye testing. The nurse reads in the child's chart that the Hirschberg test demonstrated displacement of light reflection in one eye. What does this indicate to the nurse?

Presence of strabismus

A child needs hearing assessments. To assess air and bone conduction of sound, which assessment technique is most appropriate?

Strike a tuning fork, place it on the mastoid process, then move it to within1 inch of the ear canal.

A child is in the clinic to follow up on a blood lead level of 7 µg/dL. What action by the nurse is best?

Teach parents to wet-mop surfaces instead of vacuuming the house.

A father brings his 10-month-old infant to the well-baby clinic and expresses frustration that his child "puts everything in her mouth" and "gets into everything," then cries when objects are taken away. In providing anticipatory guidance, what action by the nurse is the most appropriate?

Teach the father that this behavior is normal and not misbehaving.

A nurse has been asked to perform a Romberg test on a school-age child. What action does the nurse take to perform this assessment?

Tell the child to stand, close his or her eyes, and hold the arms out in front.

A nurse observes several preschool-aged children during play and overhears one of them say "My mommy won't let me do that." What conclusion is the most appropriate by the nurse regarding this child's development?

The child has developed a superego according to Freud.

A nurse is assessing a 1-year-old child who weighed 7 lb, 8 oz at birth. Today's weight is 23 lb. What conclusion can the nurse make about the child's weight?

The child is at an expected weight.

A 2-year-old is seen for a well-child visit and is scheduled to receive immunizations. The child weighed 22 lb (9.97 kg) at 1 year of age (1 year ago). Today the child weighs 23 lb (10.4 kg). Which conclusion is most appropriate for the nurse to make regarding this assessment data?

The child is underweight for age.

A young couple brings their 20-month-old daughter to the pediatrician's office for immunizations. The mother tells the nurse that she is going back to work and is looking for a day-care center in the vicinity of the clinic. What assessment is priority before recommending a day-care center that would help the parent and child adapt to the experience?

The child's temperament

A father is frustrated that his child frequently disobeys well-established rules and then attempts to excuse the action by stating "Well I just thought . . . ." The father asks for guidance with discipline. What information is most appropriate for the nurse to provide?

This is a normal developmental stage.

The pediatric nurse clarifies the history of a child who is brought to the emergency room with abdominal pain. The nurse uses the mnemonic OLD CAT to ask the appropriate questions, including which of the following?

Timing

The pediatric nurse working in a hospital setting uses both standard precautions and transmission-based precautions for patients. Which patient requires only standard precautions?

Tonsillitis

The pediatric nurse explains to a new mother that two factors, "nature" and "nurture," may influence the formation of her child's essence. Which factor among the following would be considered "nature"?

Traits inherent in the infant

A 5-year-old child is having an acute asthma attack. How does the nurse position the child while waiting for a respiratory treatment?

Upright in the tripod position

A preschool-age child is going to have a potentially painful procedure. What action by the nurse is best to prepare the child for this event?

Use play to demonstrate the procedure to the child.

A nurse is providing nutritional information to a parent group. Which information is most appropriate?

Use whole milk until your child is 2 years old.

A nurse is attempting to assess a toddler, who is being uncooperative. What action by the nurse would be best to accomplish this task?

Visit with the parent for a short while.

A nurse has assessed a 14-year-old hospitalized patient over several days and notes that the child has difficulty with abstract concepts and is unable to appreciate diverse points of view. According to Piaget, how would the nurse categorize this child's development?

Behind in development

A pediatric nurse works with the family of twins at designated stages in their lives to help the parents anticipate and move through the periods of disequilibrium. What is the model of child development that focuses on disruptive periods of development?

Brazelton's touchpoints model of development

The pediatric nurse assessing a patient for breath sounds documents a loud, high-pitched sound heard only over the trachea. The nurse should document this finding as which of the following?

Bronchial breath sound

A father is at the bedside of his hospitalized disabled child. He begins crying, saying he has lost his job and no longer has insurance, so he is unsure of how to pay for the child's medical bills. What action by the nurse would be most helpful?

Consult with a social worker who can discuss state and federal insurance programs.

A nurse is observing infants at a day-care center to determine how their behavior fits into attachment theories. The nurse notes a wide variety of attachment behaviors. What other assessment is appropriate for the nurse to make?

Cultural background

A student nurse asks a pediatric nurse what cephalocaudal development means. Which response by the nurse is most accurate?

Growth that occurs from top to bottom

A student nurse on the pediatric floor finds a patient in pain and gives the child some toys to play with. The registered nurse asks why the student did not medicate the child. The student states that because the child was easily distracted, it did not appear that the child needed pain medication. What action by the registered nurse is most appropriate?

Have the student reassess the child's pain.

A nurse educator is presenting developmental theories to a group of students. Which statement encompasses the impact that Carol Gilligan had on developmental theories?

Helped define moral development in women as unique from men

A nursing manager is concerned about frequent errors on the pediatric unit and wants to decrease them. What action by the manager is best?

Institute a standardized handoff format at shift change.

A mother takes her 10-year-old son to the pediatrician for a sprained wrist. During the medical history, the pediatric nurse listens to the mother describe her son as "busy playing basketball all day long with the other boys in the neighborhood." Based on the nurse's assessment, which stage of Freud's psychosocial development is this child experiencing?

Latency stage

A couple brings their child to the well-child clinic for guidance in improving the child's school performance. The nurse assesses the child and finds that favorite activities are running, playing basketball, and building models. Which conclusion is most appropriate for the nurse to make based on the assessment findings?

Learns best through bodily activity

A 7-year-old hospitalized for a fracture following a car crash tells the pediatric nurse "God is in heaven with his angels and is looking down on me." Which stage of Fowler's spiritual development is this child exhibiting?

Mythical-literal stage

A child is in the emergency department following an overdose of acetaminophen (Tylenol). What medication does the nurse anticipate administering?

N-acetylcysteine (NAC)

A toddler is brought to the clinic with a low-grade fever and the mother describes a grunting sound made by the child on expiration. The respiratory rate is 24 breaths/minute. What action by the nurse is most appropriate?

Obtain an oxygen saturation; notify provider.

A school-age child with asthma came to the emergency department with a respiratory rate of 44 breaths/minute and wheezes heard throughout. After two breathing treatments, the nurse assesses a respiratory rate of 8 breaths/minute and hears no wheezing. The child is lying quietly on the bed. What action by the nurse is best?

Obtain oxygen saturation; notify provider.

A mother brings her severely disabled child to the pediatric clinic with complaints that the child has his fourth upper respiratory infection in 3 months. The mother appears disheveled and fatigued. What action by the nurse is best?

Offer the mother information on local respite care options.

A child who weighs 35 lb needs chloral hydrate (Aquachloral) for sedation prior to a medical procedure. What dose should this child receive?

1,000 mg

A nurse working on a pediatric unit teaches a student nurse that children may require intravenous fluids to be administered through one of several different venous access devices. The nurse tells the student that which of the following current patients are candidates for central venous access devices? (Select all that apply.)

-Requires long-term intravenous access for hydration -Will need regularly scheduled chemotherapy

A pediatric nurse needs to administer acetaminophen (Children's Tylenol) to patients in the intensive care unit (ICU). Which dose, based on age, is correct?

0 to 3 months, 40 mg

A nurse is assessing several children during a shift at the well-child clinic. Which child demonstrates successful resolution of the Erikson stage of autonomy versus shame and doubt?

A 24-month-old being allowed to independently dress himself

A 66-lb child complains of mild pain after a procedure. What action by the nurse is best?

Administer 300 mg of acetaminophen (Tylenol) orally and provide a movie to watch.

A 12-year-old child is in the hospital for an extended period of time. Which action by the nurse would most promote the child's sense of self-esteem?

Allow the child to set a daily schedule for activities.

A nurse needs to administer medication to a toddler. What action by the nurse is most likely to gain cooperation from the child?

Allow the parent to give the medication.

A child will be hospitalized in the following week. In order to decrease the child's and parents' stress related to the hospitalization, which action by the clinic nurse would be most helpful?

Arrange for the family to visit the hospital and have a tour.

The pediatric nurse caring for children with physical disabilities teaches the student nurse that coping mechanisms give rise to resiliency in children and their families. The nurse further notes that attributes of resilient children include which of the following? (Select all that apply.)

-Problem-solving skills -Sense of purpose and future -Social competence

The pediatric nurse is examining a newborn infant and notes a turning in of the foot and turning out of the toes when the sole of the foot is stroked. Which action by the nurse is most appropriate?

Document the findings in the patient's chart.

A nurse uses Urie Bronfenbrenner's theory to guide practice. In order to determine a child's microsystem, which items should the nurse assess? (Select all that apply.)

-Family -Peer group -School

The pediatric nurse teaches the parents of a 3-month-old baby the principles of growth and development that will occur in their child's lifetime. Which statement accurately describes one of these principles?

Each child progresses through predictable stages within a predictable timeframe.

A parent is frustrated that her toddler wants to do everything on his own and in "my way." The parent wants to know the appropriate way to discipline the child for not obeying and allowing the parent to dress him quickly in the morning. Which response by the nurse is most appropriate?

"I know it's frustrating, but being independent is a very important job at this age."

The pediatric nurse is assessing a teenager's past medical history. Which information should the nurse inquire about? (Select all that apply.)

-All acute illnesses -Any chronic illnesses

The pediatric nurse teaches the mother of a toddler how to choose appropriate toys/activities to stimulate growth and development of her child. Which activities are appropriate for the nurse to include in the teaching session? (Select all that apply.)

-Tricycle -Large crayons -Sliding down a slide

The pediatric nurse is assessing a 5-year-old for developmental milestones. Which assessment tool should the nurse use?

Denver II screening tool

A 15-year-old adolescent tells the school nurse that he is busy preparing for a forensics competition and would like to be a lawyer one day. According to Piaget's stages of development, the adolescent is in which stage of cognitive development?

Formal operational stage

The pediatric nurse performs a pain assessment on a 5-year-old girl who is admitted to the hospital for fractures following an accident. Depending on the assessment, the nurse could implement which of the following interventions? (Select all that apply.)

-Manage mild pain with a combination of mild analgesics such as NSAIDs and distraction. -Manage moderate pain with distraction plus regularly timed analgesic administration. -Manage severe pain with strong analgesics such as morphine sulfate (Astramorph).

A mother brings her 8-year-old son into the clinic for a well-child visit. She is concerned because her son does not take responsibility for completing and handing in his school assignments on time, and his teacher has given him several warnings for missing homework. Which responses are appropriate for the nurse to this child's mother? (Select all that apply.)

-"As a parent, you should refrain from rescuing your child from the consequences of his behaviors and allow him to learn a valuable lesson from them." -"At 8, children can internalize rules, so it's important to allow him to be responsible for his actions and to accept the consequences of his behavior."

A nurse is providing anticipatory guidance to the parents of a 5-month-old baby. Which nursing statements are appropriate by the nurse to these parents? (Select all that apply.)

-"Do not leave the child alone on the changing table." -"Peek-a-boo is an appropriate game for this age."

A nurse is working with a child who has a chronic illness requiring medication and frequent hospitalizations. The parents refuse to allow the child to go to the playroom, fearing germs from other children will harm their child. Which actions by the nurse are most appropriate? (Select all that apply.)

-Allow the parents to voice their concerns without being judgmental. -Help the parents see the ways their child is normal while having an illness.

A toddler has been adopted from a foreign country and has the nursing diagnosis of delayed growth and development related to poor nutrition. Which activities should the nurse include in the plan of care to assist the child to meet outcomes? (Select all that apply.)

-Allow toddler to choose foods within appropriate parameters. Consult with a dietician to provide a high-calorie, high-protein diet.

The nurse conducts a seminar for new nurses about child safety in the hospital setting. Which of the following should be included? (Select all that apply.)

-Basing safety measures on the developmental level of the children -Providing age-appropriate transportation methods to other areas of the hospital -Storing toxic and nontoxic materials on the top shelf of a locked cabinet

A nurse is teaching parents about appropriate discipline for their toddler. Which information is appropriate for the nurse to include in the session? (Select all that apply.)

-Be firm and specific but respectful. -Deliver consequences immediately. -Tie consequences to the action if possible. -Try to anticipate and avoid tantrums.

What does the pediatric nurse understand about the use of complementary and alternative medicine (CAM)? (Select all that apply.)

-CAM practices reflect ethnocultural health beliefs. -Very few doctors collaborate with CAM providers.

The nurse is preparing to educate the parents of an 8-year-old child about normal growth and development. Which information should the nurse include? (Select all that apply.)

-Children frequently have best friends at this age. -Puberty changes should be discussed before they occur. -Typical weight gain is 4-6 lb (1.8-2.7 kg)/year.

A nurse educator is discussing developmental theories with a student. What information is appropriate for the educator to provide regarding Lev Vygotsky's theory? (Select all that apply.)

-Children learn best with assistance from someone else. -Culture plays a vital role in language development.

The nurse is preparing to provide information to the parents of a 14-year-old who is within normal limits for growth and development. What information is appropriate for the nurse to include? (Select all that apply.)

-Children of this age can anticipate long-term consequences of choices. -Growth, although slowed, can still be significant. -The child of this age may be able to give informed consent in some situations. -Peer group influence is often stronger than family influence.

A nurse is providing anticipatory guidance to the parents of a school-age child. What information is appropriate for the nurse to include for school-age children? (Select all that apply.)

-Discuss physical changes related to puberty. -Discuss smoking and substance abuse. -School-age children require 8 to 12 hours of sleep each night.

A school nurse is working with high school students. The nurse wants to influence these teenagers to make healthy decisions. Which actions are most appropriate by the school nurse to influence health decisions? (Select all that apply.)

-Discussing without judging -Encouraging critical thought -Listening carefully to the teen -Paying attention to nonverbal cues

A nurse has been asked to perform a HEENT assessment on a child. What areas does the nurse assess? (Select all that apply.)

-Eyes -Head -Nose -Throat

The pediatric nurse takes a comprehensive health history of a 10-year-old patient and asks the parents about their use of herbal products or home remedies. What information does the nurse know regarding herbal products?

Echinacea is contraindicated for patients with autoimmune disorders.

A parent of a teething child asks for guidance on nonpharmacological treatments for gum pain. What herbal preparation can the nurse suggest?

Chamomile

Which outcome is most appropriate for a 3-year-old with the nursing diagnosis of delayed growth and development related to chronic illness?

Child will draw using large crayons in 2 months.

A hospitalized 11-year-old child turns down opportunities to play or engage in diversionary activities. When questioned, the child states "I'm bad at that" or "I can't do anything." What action by the nurse is best?

Consult the child developmental specialist.

A pediatric nurse reads in a chart that a female patient is in Tanner stage 3. Which of the following best describes this patient?

Entire breast enlarged; pubic hair in inverted triangle

A new nurse caring for a toddler in pain after a procedure is reluctant to medicate the child for fear of causing a respiratory arrest. What action by the nurse's preceptor is best?

Explain that pain has detrimental health effects and needs treatment.

A mother is worried that her 3-month-old child is not holding her own head up. Which action by the nurse is most appropriate?

Explain that sturdy head control occurs around 6 months.

A teenager is in the family practice clinic for a school physical. When the parent leaves the room, the teen admits to "cutting myself" after a relative "touched me in my private area." What action by the nurse is most appropriate?

Explain that this information must be shared.

A pediatric nurse examines a 7-year-old at a well-child visit. Based on Erikson's theory, which basic task does the nurse anticipate for this child?

Develop a sense of confidence through mastery of different tasks.

A parent is frustrated that her toddler cannot button a shirt on his own. Which teaching point is most appropriate for the nurse to provide to this parent?

Developing large muscle groups has to occur before developing small muscle groups.

A 1-week-old infant is in the pediatric clinic. The birth weight was 8 lb, 1 oz (3.65 kg). Today the infant weighs 7 lb (3.17 kg). The mother breastfeeds exclusively. What action by the nurse is best?

Document the finding and alert the provider.

A nurse is listening to a school-age child's heart sounds and hears an abnormal noise after S2 that is heard best when the child is lying in the left lateral position. What action by the nurse is most appropriate?

Document the findings in the chart.

A 10-year-old child who has been hospitalized frequently and for long periods of time has the nursing diagnosis of delayed growth and development. Which action by the child would demonstrate that outcomes for this diagnosis have been met?

Does own homework independently