PEDS Practice: Chapter 11 Caring for Children in Diverse Settings

The mother of a 7-year-old child reports to his assigned nurse that she will need to leave for the night to care for her other children at home. She says she is worried about how her son will do, so she plans to slip off when he falls asleep. What response by the nurse is appropriate?

"Children do best with honesty, so I would recommend you tell him you will need to leave." When children are ill and hospitalized it is important to establish and maintain trust. Honesty within the confines of what they are developmentally able to understand is important. The mother should be encouraged to tell her child the truth. Not telling him may result in him becoming very upset if he awakens and his mother is not there. While children are resilient this is not promoting trust and honesty. pg 344

The student nurse is assisting the more experienced pediatric nurse. Which statements by the student indicate further education is required? Select all that apply.

"I'm going to redress the child's IV site while she is in the playroom." "I took our new teenaged child down to show him the playroom." "It would be easy to perform a straight catheterization while the baby is in his crib."

The nurse is working with the caregivers and families of children who are hospitalized. Members of the group make the following statements. Which statement gives an indication of an issue that would likely be a major factor influencing the family's response to the child's illness?

"Sometimes I wonder if the reason she is sick is because I have so many responsibilities at work and at home." The child's family suffers stress for a number of reasons. In this situation the caregiver felt guilt about the illness. The cause of the illness, its treatment, guilt about the illness, past experiences of illness and hospitalization, disruption in family life, the threat to the child's long-term health, cultural or religious influences, coping methods within the family, and financial impact of the hospitalization all may affect how the family responds to the child's illness. Although some of these are concerns of the family and not specifically the child, they nevertheless influence how the child feels. page 333

The nurse is talking with the parents of a 6-month-old girl hospitalized with a respiratory infection. The parents state, "Since our child is so young it will be easier for her to cope with us being at work all day." How should the nurse respond?

"Is there a familiar person in your child's life that might be able to spend time with her while you're at work?" By 5 to 6 months of age, infants have developed an awareness of self as separate from mother. As a result, infants of this age are acutely aware of the absence of their primary caregiver and become fearful of unfamiliar persons. If the parents must both be at work, a familiar person to be with the child would be beneficial. Telling the parents the child will be fine may be instilling false hope. "Just be prepared for her to show signs of separation anxiety..." is not supportive and may cause the parents to feel guilty. "...I will be happy to give her extra attention when you both are at work" may be making promises that the nurse can't keep, and the nurse is still a stranger to the child. page 315

The nurse is educating the parents of a 7-year-old boy, scheduled for surgery, to help prepare the child for hospitalization. Which statement by the parents indicates a need for further teaching?

"It is best to wait and let him bring up the surgery or any questions he has" It is important to be honest and encourage the child to ask questions rather than wait for the child to speak up. The other statements are correct. pg 331

The nurse is caring for a preoperative pediatric client. What would it be best for the nurse to do with this client?

Determine how much the child knows and is capable of understanding. The nurse must determine how much the child knows and is capable of learning in order to best prepare the child for surgery. Keeping terminology at the child's and caregivers' level of understanding is important when doing teaching. page 323

The grandmother of a 1-year-old cancer patient comes to visit the child in the PICU. She sits in a chair near the child's bed but doesn't touch him. Which action by the nurse would be most appropriate?

Encourage the grandmother to rock the child in a rocking chair.

A nursing instructor is reviewing a care plan written by a student on a hospitalized child. Which nursing intervention for the diagnosis of self-care deficit related to regression would the nursing instructor question?

Encourage the parents to do as much self-care for the child as possible. Appropriate nursing interventions for the diagnosis of self-care deficit related to regression include encouraging the child and family, not just the child, to perform as much self-care as possible. Assessing usual home routines, providing appropriately sized equipment, and encouraging rest periods are all appropriate nursing interventions for this diagnosis.

The charge nurse is reviewing room assignments for a 5-year-old child who is very tearful. Which room assignment would be best?

In a room with a child near the same age Placing the child in a room with a child near the same age would be beneficial. This would promote sharing and bonding over similar circumstances. Rooming alone may promote feelings of isolation and despair. Placement with an older or younger child would not be of mutual benefit.

The registered nurse is creating a care plan for a hospitalized child. She has identified anxiety related to hospitalization as a nursing diagnosis. Which interventions would be most appropriate to include? Select all that apply.

Orient the child and family to the unit and room. Assess for signs and symptoms of anxiety and fear. Explain all events, treatments and procedures to the child and family. Encourage the patents to inform the child when they are leaving and when they will be back. Place the child in a semi-private room with a child of similar age if possible rather than in a private room. Orienting the child and family to the room and unit, assessing for signs and symptoms of anxiety and fear, explaining all events to both the child and family and encouraging the parents to inform the child when they are leaving and when to expect them back are all appropriate interventions for this diagnosis. page 344

The nurse is reviewing a job description of a school nurse. Which activity would the nurse question?

Provide immunizations to students. School nurses typically don't administer vaccines to children. They act as a liaison between the child and various health care provider and other community agencies. Training staff and students on topics such as first aid, CPR, and health promotion activities, and providing emergency first aid are examples of activities of the school nurse.

The nurse is preparing to discharge a 5-year-old child from the hospital who will require dressing changes to a wound at home. The parents have been taught the appropriate wound care measures during the stay in the hospital. Which action by the parents assures the nurse that learning occurred?

The parents have performed the wound care and dressing change with the nurse's supervision the last 2 days prior to discharge Demonstration of wound care is the best way to evaluate if the parents are knowledgeable of the procedure. Voicing understanding and listing the steps don't assure the nurse that learning occurred. Helping the nurse with the wound care is beneficial when initially learning the procedure, but does not ensure the ability to perform the procedure independently. page334

A nurse with no pediatric experience has been transferred to a pediatric unit to work for the day. Which comments by the nurse indicate knowledge of developmental considerations when providing hygiene needs to a 3-month-old infant?

"I plan on using a sponge bath to bathe the infant." A 3-month-old would require a sponge bath or tub bath to bathe because they cannot sit unaided. Talcum powder is not suggested for infants. A bathtub can be used for toddlers or older. No child should ever be left alone during bathing for any length of time. page 329

The nurse is providing teaching for the parents of an 8-year-old girl who has undergone surgery. The nurse emphasizes the importance of maintaining adequate hydration. Which response by the mother would indicate a need for further teaching?

"I will remind her that she will need an IV if she does not drink." The child is likely to view an IV both as frightening and as punishment. Intravenous fluids should be seen as therapy. Threats such as this should not be used to achieve compliance with eating or drinking. The other statements show understanding.

A 12-year-old boy is admitted to the hospital for gastrointestinal illness. The child's parents tell the nurse that their son is normally very outgoing and happy but "as soon as we came to the hospital, our son acted so differently. I know he is sick but this was something different." What is the best response by the nurse?

"Tell me about your son's previous experience with hospitals, both with himself and loved ones."

The nurse is caring for a preschooler who is hospitalized with a suspected blood disorder and receives an order to draw a blood sample. Which approach is best?

"Why don't you sit on your mom's lap?" It is best to include the families whenever possible so they can assist the child in coping with their fears. Preschoolers fear mutilation and are afraid of intrusive procedures. Their magical thinking limits their ability to understand everything, requiring communication and intervention to be on their level. Telling the child that we need to put a little hole in their arm might scare the child. page 323

A nurse is caring for a 6-year-old boy hospitalized due to an infection requiring intravenous antibiotic therapy. The child's motor activity is restricted and he is acting out, yelling, kicking, and screaming. How should the nurse respond to help promote positive coping?

"Would you like to read or play video games?" Distraction with books or games would be the best remedy to provide an outlet to distract the child from his restricted activity. The other responses would be unlikely to affect a change in the behavior of a 6-year-old. page 317

The nurse is preparing a 4-year-old girl for a lumbar puncture. The child is extremely fearful and crying. The nurse needs to quickly gain the child's cooperation so the procedure can move forward as ordered. Which approach by the nurse should be used?

Engage the mother in therapeutic hugging. Often therapeutic hugging will calm a child and keep the youngster still for a procedure. Asking the child to calm down or telling her everyone is trying to help will not assist the child adequately for her to be able to cooperate. Alternate measures should be tried before using a restraint, and the least restrictive type of restraint should be used. A mummy restraint is quite restrictive. page 327

The father of a 5-year-old child reports that he uses a series of local urgent care centers for routine care. What is the greatest concern about this practice?

It is difficult to have continuity of care with these practices. The American Academy of Pediatrics discourages children and families from using urgent care centers or the emergency department for routine care, since it is difficult to provide coordinated, comprehensive family-centered care consistent with a "medical home" concept. page 337

What will the nurse view as best maintaining normalcy in the life of a 10-year-old boy who is experiencing a lengthy hospitalization?

Keeping up with his schoolwork A school-ager is exactly that—someone whose life is centered around school. Doing school and homework assignments is part of his usual day when not hospitalized. Watching daytime TV is not. Choosing the time hygiene activities occur provides him some control, while tracking his oral intake is an opportunity to participate in his care. Playing board games with the child life specialist is an age-appropriate activity that provides distraction. These support him developmentally but do not normalize his day as does keeping up with school assignments. It will be easier for him to return to the classroom and feel more in step with his peers by doing this. pg 324

The nurse is preparing a postsurgical care plan for an infant girl located on a general hospital unit that only occasionally admits children. To ensure the infant's safety, what should the nurse include in the plan?

Place the infant in a room close to the nurses' station. The infant will need close monitoring, and having the child nearby will promote frequent checks and awareness of her status. Family cannot be required to stay at all times. That may be impossible for some. One client should never be responsible for another. The infant is the nurses' responsibility. Putting the infant in a carrier and bringing her to the nurses' station is not safe. page 324

A 6-year-old will be hospitalized for a surgical procedure. How can the nurse best ease the stress of hospitalization for this child?

Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital. The best way to ease the stress of hospitalization is to ensure that the child has been well prepared for the hospital experience. page 313

The charge nurse is planning staffing on a pediatric unit. The charge nurse is aware that the majority of admissions for children under the age of 5 years are for diseases of which body system?

Respiratory According to Child Health USA 2010, diseases of the respiratory system, such as asthma and pneumonia, account for the majority of hospitalizations in children younger than 5 years of age, while diseases of the respiratory system, mental health problems, injuries, and gastrointestinal disorders lead to more hospitalizations in older children. page 313

A nurse is using a doll to explain what will be done when starting an intravenous (IV) line on a 4-year-old. What type of play is this?

Therapeutic play Therapeutic play is a technique to help children better understand what will be happening to them in a specific situation. For instance, the child who will have an IV line started before surgery might be given the materials and encouraged to "start" an IV on a stuffed animal or doll. page 332

The nurse is working with a group of caregivers of children in a community setting. The topic of hospitalization and the effects of hospitalization on the child are being discussed. Which statement made by the caregivers supports the most effective way for children to be educated about hospitals?

We are going to take our child to an open house at the hospital so she can see the pediatric unit." Families are encouraged to help children at an early age develop a positive attitude about hospitals. The family should avoid negative attitudes about hospitals. Some hospitals have regular open house programs for healthy children. Children may attend with parents or caregivers or in an organized community or school group. page 320

The nurse is speaking to a hospitalized child's parent about ways to encourage good nutrition while the child is hospitalized and after discharge. Which statement by the parent would indicate the need for further education?

"I will make the menu choices for my child so I make sure he is getting a balanced diet." Offering the child choices and allowing the child to choose what he or she wants from the menu helps to promote nutrition. Having family present for meals, using familiar objects such as sippy cups and offering ice chips as fluid intake are all additional ways to promote nutrition in hospitalized children.

A nurse realizes that a child's hospitalization is stressful for the family for which reasons? Select all that apply.

Cause of the illness The illness's treatment Guilt about the illness Past experiences of illness and hospitalizations Disruption in family life

The nurse is caring for an 18-month-old boy hospitalized with a gastrointestinal disorder. The nurse knows that the child is at risk for separation anxiety. The nurse watches for behaviors that indicate the first phase of separation anxiety. For which behavior should the nurse watch?

Crying and acting out Children in the first phase, protest, react aggressively to this separation, and reject others who attempt to comfort the child. The other behaviors are indicators of the second phase, despair.

The nurse has been assigned to care for a child who is on transmission-based precautions. This nurse has not cared for this child before. Which action would be the best way to help the child feel comfortable with the nurse?

Let the child see his or her face before the mask is put on. If masks or gloves are part of the necessary precautions, the child may experience even greater feelings of isolation. Before putting on the mask, the nurse should allow the child to see his or her face; this process will help the child easily identify the nurse. Being introduced by the previous nurse, reading to the child, or explaining that the caregiver will visit soon are appropriate but are not the best ways to help the child feel less isolated and more comfortable with the nurse in the isolation setting.. page 322

The nurse is speaking to a hospitalized child's parent about ways to encourage good nutrition while the child is hospitalized and after discharge. Which statement by the parent would indicate the need for further education?

"I will make the menu choices for my child so I make sure he is getting a balanced diet." Offering the child choices and allowing the child to choose what he or she wants from the menu helps to promote nutrition. Having family present for meals, using familiar objects such as sippy cups and offering ice chips as fluid intake are all additional ways to promote nutrition in hospitalized children. page 331

The nurse is caring for a 7-year-old boy in a body cast. He is shy and seems fearful of the numerous personnel moving in and out of his room. How can the nurse help reduce his fear?

Write the name of his nurse on a board and identify all staff on each shift, every day. The best approach would be to write the name of his nurse on a small board and then identify all staff members working with the child (each shift and each day). Reminding the boy he will be going home soon or telling him not to worry does not address his concerns or provide solutions. Encouraging the boy's parents to stay with him at all times may be unrealistic and may place undue stress on the family. pg 319

The nurse is caring for a 3-year-old child who is hospitalized for pneumonia. When considering his developmental age and need for security, which statement by the nurse after an invasive procedure would be most helpful?

"I am proud of how you were such a good boy." Toddlers and preschoolers may attribute illness and hospitalization a punishment for wrong deeds or misbehavior. Communicating to them that they are "good" and well behaved is beneficial. Calling them a "big boy" while flattering will not have the same impact as alleviating fears of misbehavior for this age group. While they are likely relieved the procedure is over, saying it is not helpful. Telling them you explained they would be "ok" is not of benefit. pg 315

The nurse is caring for a preschooler who requires postsurgical breathing exercises. Which approach will best elicit the child's cooperation?

"Let's see who can blow these cotton balls off the table first." Any intervention should be developmentally appropriate, and play can often serve as a vehicle for care. Turning breathing exercises into a game is likely to engage the preschooler. Telling the child he needs to do breathing exercises or he will develop another illness or not feel better is not likely to impress the young child. Connecting the two events in a meaningful way is beyond his cognitive ability. Asking if the child "wants" to play a breathing game is an open invitation for a "No" answer. page 323

A mother in the outpatient setting is explaining how she plans to prepare her 5-year-old for hospital admission. What remark indicates the parent requires additional teaching?

"We told him to use his manners and behave like a big, brave boy." Expecting manners and brave "big-boy" behavior is unrealistic. The child's coping skills are not yet well developed. Expressing true feelings should be allowed. The other preparations are helpful and promote understanding of the experience. page 317

The nurse has applied a restraint to the child's right wrist to prevent the child from pulling out an intravenous line. Which assessment findings ensure that there is proper circulation to the child's right arm? Select all that apply.

Capillary refill is less than 2 seconds in upper extremities bilaterally Fingers are pink and warm bilaterally Radial pulses are easily palpable bilaterally It is important to assess the child's peripheral vascular circulation especially when the child has a restraint placed on an extremity. Capillary refill, color, temperature, and pulses are appropriate to assess to ensure that the child's peripheral vascular circulation has not been compromised. pg 326

The nurse is preparing to apply restraints to a child who has become combative. What actions will be included in the nurse's plan of care? Select all that apply.

Remove restraints and perform range of motion activity every 2 hours. Explain to both the child and parent the restraints are not a form of punishment. Document application of restraints in the child's medical record. Before applying a restraint, explain the reason for the restraint to the child and the parents. Emphasize that the rationale is to maintain the child's safety; the restraint is not punishment. Having the child and parents state the reason for the restraint demonstrates their understanding. After applying the restraints an initial assessment must be performed in 15 minutes and then every hour. At least every 2 hours the restraints should be removed and range of motion performed. The restraints are to be tied to the bed or crib frame and not the bed's side rails. pg 326

The nurse is caring for a 10-year-old boy who had an appendectomy 2 days ago. Prior to surgery he had expressed that he was worried that after the procedure he would hurt and have lots of pain. The nurse asks the child what his pain level is on a scale of 0 to 10, with 10 being the worst pain. He tells the nurse he has no pain. The most appropriate action by the nurse would be to:

observe him for physical signs which might indicate pain. Nursing judgment is in order. Some children may try to hide pain because they fear an injection or because they are afraid that admitting to pain will increase the time they have to stay in the hospital. To use the color scale, a child younger than 7 is given crayons ranging from yellow to red or black. Yellow represents no pain; the darkest color (or red) represents the most pain. The child selects the color that represents the amount of pain he or she feels.

A nurse who has worked in a variety of settings over the past several years is trying to determine what setting she would most like to work in now. The nurse is very organized, works well in an autonomous environment, and prefers one-on-one care. Which setting would best fit this nurse's needs?

Home Health Home health would provide the most autonomy (which requires being organized), and takes place in the client's home, giving one-on-one care. All areas of nursing require organization in order to provide efficient care. A physician's office would likely provide the least amount of autonomy since the physician is always present, as well as other office staff. The health department nurse and the school nurse would favor an autonomous person, but there is still more direct supervision than with home health nursing. pg 341

A few days after discharge, the parent of an 8-year-old calls the pediatric clinic, concerned about the child's behavior now that she is home. The parent expresses that the child is treating her siblings badly and using language she knows she is not allowed to use. The parent asks the nurse for suggestions regarding how to handle this behavior. Which statement would be most appropriate for the nurse to make to this parent?

"Respond to her behavior in a firm, loving, consistent way." The return home may be a difficult period of adjustment for the entire family. The older child may demonstrate anger or jealousy of siblings. The family may be advised to encourage positive behavior and to avoid making the child the center of attention because of the illness. Discipline should be firm, loving, and consistent. The child may express feelings verbally or in play activities. The family may be reassured that this is not unusual.