Chapter 30: Basic Pediatric Nursing Care NCLEX QUESTIONS QUIZ 8

42. The nurse is aware that visual acuity evaluation in a child is best assessed after the age of _____ years. ANS: 6 six

A child's refraction does not reach 20/20 until about the age of 6.

41. The pediatric nurse, along with the primary caregiver(s), has a special duty to ________ the child and the family.

ANS: teach The pediatric nurse is in a position to assess, instruct, and support children and their families about developmental progress, nutrition, and possible undiagnosed anomalies.

34. When the nurse is inserting a feeding tube in an 8-month-old, what safety reminder device (SRD) should the nurse most likely use? a. Mummy b. Clove hitch c. Jacket device d. Elbow device

ANS: A The mummy restraint controls the arms and the body of the infant.

15. The mother of a 3-year-old expresses concern about her daughter's slowed growth rate. What would be the most informative response by the nurse? a. "Three-year-olds have typically finished a growth spurt, and you may notice a decreased rate in your daughter's growth." b. "Children's growth is hereditary. She may be of small stature like you." c. "The growth of a 3-year-old is associated with their nutrition. How is she eating?" d. "Your daughter is healthy and happy. Don't worry about her growth right now."

ANS: A Three-year-olds slow down in their growth in a natural cycle.

40. The nurse clarifies that the family-centered care approach terminates which policies? (Select all that apply.) a. Rigid visiting hours b. Freedom to choose which medications to take c. Exclusion of family during procedures d. Discouraging family to stay overnight e. Restricting parents from reading the chart

ANS: A, C, D, E Family-centered care terminates all the restrictive policies of traditional hospitals. Medication orders should still be followed.

39. The nurse welcomes the presence of the family in a pediatric unit because it reduces the stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.) a. Separation b. Lack of love c. Fear of pain d. Unfamiliar food e. Loss of control

ANS: A, C, E Parents lend stability and comfort for the child and restore his or her sense of control.

30. Where is the typical IV insertion site in an infant younger than 9 months of age? a. Radial vein b. Scalp vein c. Femoral vein d. Brachial vein

ANS: B A superficial scalp vein is the injection site for administering IV medication to infants

21. How should an infant be positioned after a feeding? a. On the stomach b. On the right side c. On the left side d. On the back

ANS: B After feeding, the infant is positioned on the right side to direct the food into the stomach.

22. When a safety reminder device (SRD) is used to protect a child, what is a responsibility of the nurse? a. Apply it loosely b. Remove it every 2 hours c. Place it over clothing d. Apply only one type

ANS: B Any SRD should be removed every 2 hours.

33. A disfiguring facial wound would have the most significant developmental impact on which child? a. 4-year-old b. 6-year-old c. 10-year-old d. 14-year-old

ANS: D The adolescent fears a change in body image associated with surgery.

12. An 8-year-old child asks how a blood pressure is taken. What would be the most appropriate response? a. "This small machine will measure your systolic and diastolic pressure." b. "The armband will hug your arm and tell me how well your blood is going through your arm." c. "The armband will cut off your circulation for a while and then we can hear when it comes back." d. "When you are ill we need to know if your blood is still moving in your body."

ANS: B Because children are upset by unfamiliar procedures, it is best to explain each step in simple terms. It is best not to mention anything that may increase anxiety.

31. Following a lumbar puncture of a 2-year-old, what should the nurse do? a. Keep the child flat for several hours b. Allow the child to play quietly at will c. Hold the child in a flexed position for 5 minutes d. Stand the child upright immediately

ANS: B Children younger than 3 years of age are usually not affected by postlumbar headache. These children are allowed to play at will following a lumbar puncture.

9. What activity by an infant would cause a false elevation of the tympanic temperature? a. Having a bowel movement b. Crying vigorously c. Having just eaten d. Having been in a cold room

ANS: B Crying increases the temperature; eating and bowel movements do not. A cold room would lower the temperature.

26. What is a disadvantage of using a mist tent with a toddler? a. The nurse must remove the restless child. b. The wet bedding and clothing must be changed frequently. c. The mist tent must be opened at least once every hour. d. All objects must be kept outside of the tent.

ANS: B Frequent linen and clothing changes will be necessary because of the heavy humidity in the tent. The nurse can open the tent to soothe the restless child instead of removing the child. The tent does not have to be opened every hour. Toys can be placed inside the tent.

2. What was founded by Lillian Wald? a. National Commission on Children b. Henry Street Settlement c. White House Conference d. U.S. Children's Bureau

ANS: B Lillian Wald, regarded as the founder of public health, founded Henry Street Settlement, which provided nursing services and social assistance.

28. Why must the pediatric nurse be cautious about medicating infants and young children? a. They are less susceptible to medication effects than adults. b. They are more susceptible to medication effects than adults. c. They are equally susceptible to medication effects as adults. d. They are more susceptible to drug interactions than adults.

ANS: B Newborns and young children are more susceptible to the toxic effects of certain medications than adults.

25. What is the maximum amount of time that a nurse should suction an artificial airway? a. 1 second b. 5 seconds c. 30 seconds d. 1 minute

ANS: B The nurse should limit suctioning to no more than 5 seconds.

24. What is the purpose of a mist tent? a. To provide a constant oxygen supply b. To liquefy respiratory secretions c. To aid in lowering temperature d. To improve the infant's hydration

ANS: B The purpose of the mist tent is to liquefy respiratory secretions. A constant oxygen supply can be given by methods other than a mist tent. A mist tent does not lower temperature or improve hydration.

6. What should be the focus of a practice where the pediatric nurse uses a developmental approach? a. Stimulation of the child to reach expected norms b. Age-centered care plans c. Strengths and abilities of the child d. Characteristics for the particular age

ANS: C A developmental approach emphasizes the child's strengths and abilities and considers individuality. It builds on what the child can do instead of focusing on what the child cannot do.

32. What should the nurse do to minimize an unpleasant-tasting drug? a. Pour the drug over ice b. Squirt the drug in the mouth with a syringe c. Administer the drug through a straw d. Enlist the parent's assistance

ANS: C Administering the drug through a straw will diminish an unpleasant taste. Having the child hold the nose is helpful, as bad taste is associated with the smell of the drug. Pouring the drug over ice may result in the child not getting the entire amount of the drug. Squirting the drug into the mouth with a syringe will still allow the child to taste the medication. The parent's assistance should be enlisted, but will not minimize the taste of the drug.

19. When attempting to provide information to the parents of a child undergoing surgery, the nurse notes that the parents appear confused and do not seem to remember what they are being told. What is the most probable cause of the parents' forgetfulness? a. Noisy environment b. Serious nature of surgery c. Increased level of parents' anxiety d. Developmental age of the child

ANS: C Anxiety of the parents may result in confusion and forgetfulness. It is not known if the environment is noisy, if the surgery is serious in nature, or what is the developmental age of the child.

23. What should be done before initiating a gavage feeding? a. Hold the feeding tube under water to check for bubbling b. Check for gastric distention c. Aspirate stomach contents d. Ensure the sterility of feeding equipment

ANS: C Aspirating stomach contents and aspirating a small amount of air while listening for stomach gurgling are the best ways to ensure correct tube placement. Holding the feeding tube under water to check for bubbling is not an effective method to check tube placement. Gastric distention would be important following the feeding. A gavage feeding is not a sterile procedure.

35. The nurse clarifies that child abuse and neglect are complicated and preventable problems falling under which broader term? a. Child abandonment b. Child mismanagement c. Child maltreatment d. Child torment

ANS: C Child maltreatment is a broad term used to describe neglect and abuse of children.

1. What was one of the major strides in pediatric care made by Dr. Abraham Jacobi? a. Pediatric wards in hospitals b. Free inoculations against smallpox c. Milk stations in the city of New York d. Serving nutritious foods in orphanages

ANS: C Dr. Abraham Jacobi, referred to as the father of pediatrics, initiated the establishment of milk stations in New York demonstrating how to sanitize milk for children.

36. What observation in an emergency department should lead a nurse to suspect child abuse in a child with a fractured arm? a. Lack of parental concern for the severity of the injury b. The child not answering questions concerning the injury c. Parents not asking about the child's condition d. Inconsistency between the injury and the parents' explanation of it

ANS: D Special attention must be paid to injuries that are inconsistent with the parents' explanation.

16. What should be included in the teaching plan for the parents of a 3-year-old child who has been prescribed an opioid analgesic? a. The opioid is likely to cause significant respiratory depression. b. The medicine is prescribed with the knowledge that addiction may occur. c. The opioid is very effective as a pain control method. d. The opioid is only to be given in cases of severe pain.

ANS: C It is an effective type of analgesia. When administered to children, opioid analgesics do not have any greater respiratory depression than when given to an adult, and the risk of addiction is virtually nonexistent in children.

18. When the newly admitted 2-year-old who was potty-trained before admission begins to wet the bed, the mother is frightened. What statement by the nurse will be most helpful to the mother? a. "Don't be concerned. Accidents happen." b. "Let's put a diaper on your child until this gets better." c. "The stress of hospitalization makes children regress a little." d. "Your child will relearn 'potty-training' if you are patient."

ANS: C It is not unusual for children to regress when hospitalized. Explaining that regression is normal during hospitalization will help allay the mother's anxiety.

38. After observing parental behavior that leads the nurse to suspect child abuse, when should the nurse report the abuse? a. If the parent confesses to child abuse b. If the child admits to being abused c. Whenever maltreatment of a child is suspected d. When the type of abuse can be determined

ANS: C Mandatory reporting of child abuse is required when the health care provider has reason to suspect the child has been abused.

4. What is the special category that encompasses children who have congenital abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies? a. Very dependent children b. Children requiring special education c. Children with special needs d. Children requiring long-term care

ANS: C The definition of children with special needs includes congenital abnormalities, malignancies, GI diseases, and CNS anomalies.

13. What is the correct way to assess for the presence of jaundice in an African American child? a. Examine the sclera b. Press the edge of the pinna c. Apply pressure to the gum d. Compare the color on the soles of the feet

ANS: C The gums in individuals with dark complexions can be used to assess jaundice by pressing the gums about the teeth.

37. When communicating with parents suspected of child abuse, what should the nurse be sure to do? a. Tell them the law requires reporting of the incident b. Be sympathetic to their needs c. Interact with them in a nonjudgmental manner d. Suggest psychiatric counseling

ANS: C The nurse should maintain a nonjudgmental attitude toward the parents. The nurse does not have to tell the parents that she is reporting them. The nurse does not have to be sympathetic, she only has to be professional at all times. It is not the place of the nurse to suggest counseling.

29. What is the preferred IM injection site for a 2-year-old? a. Deltoid muscle b. Upper thigh c. Vastus lateralis d. Gluteus

ANS: C The preferred site for an IM injection for a 2-year-old is the vastus lateralis.

3. When the pediatric nurse is attempting to establish a trusting relationship with a child, what is the most important and lasting thing to do? a. Convey respect b. Talk with the child c. Be honest d. Talk with family

ANS: C To establish a trusting relationship, the most important thing is to be honest.

27. What is one way to enhance the nutrition of the hospitalized toddler? a. Reward with sweets for eating meals b. Discourage participation in noneating activities c. Offer nutritious fluids frequently d. Leave nutritious finger foods out for the child to eat

ANS: C Using nutritious liquids may satisfy the nutritional needs when a toddler is "too busy" to eat. Toddlers should not be left to eat unsupervised because of the danger of aspiration. Junk food should not be used as rewards. Activities are important and should not be discouraged.

5. The mother of a child with diabetes asks the nurse in charge of the family-centered pediatric unit if she might see her child's laboratory reports. What response by the nurse is the most appropriate? a. "Although the actual reports are not shared, I can tell you the blood sugar is 200 mg." b. "I'll write them down for you and bring them to your room." c. "Come to the conference room where we can have privacy while you look at them." d. "I'll notify the physician that you wish to see the reports."

ANS: C With a family-centered care approach, hospitals welcome parents, and parents have access to information 24 hours a day.

7. When using anticipatory guidance to prepare a 5-year-old for an IM injection, what statement by the nurse would be most appropriate? a. "Ethan, I'm going to give you a shot." b. "Ethan, the doctor wants you to have some medicine, and it will hurt." c. "Ethan, some medicine can only be given with a needle." d. "Ethan, I am going to give you some medicine that will sting, but only for a little while."

ANS: D Anticipatory guidance is the psychological preparation of a patient for a stressful event by explaining what will happen and the probable outcome.

20. What is the best time to bathe an infant? a. At bedtime b. Early in the morning c. After a feeding d. Before a feeding

ANS: D Bathing is usually done before a feeding to reduce the possibility of vomiting, regurgitation, or stimulation.

8. When measuring the head circumference of an infant, where should the nurse place the tape measure? a. Across the eyebrows and around the occipital lobe b. Over the zygomatic arches and around the parietal areas c. Around forehead and around the crown of the head d. Above the eyebrows and pinnas, and around the occipital lobe

ANS: D Head circumference is measured in children up to 36 months above the eyebrows and pinnas, and around the occipital lobe.

11. Why does obtaining the respirations of an infant require a modified approach from that of an adult? a. Infants breathe through their noses b. Infants have very rapid respirations c. Infants' respirations are thoracic in nature d. Infants' respiratory movements are abdominal

ANS: D In children under 6 or 7 years of age, respiratory movements are abdominal or diaphragmatic. Abdominal movements must be observed when counting respirations.

14. When discussing growth and development with the parents of a child, the nurse explains that nutrition is the single most important influence on: a. cognitive development. b. secondary sexual characteristics. c. the production of blood cells. d. the growth of bones and muscle.

ANS: D Nutrition is probably the single most important influence on growth.

17. The parents ask about preparation of their toddler for hospital admission. When does the nurse suggest that the parents tell their toddler of the admission? a. A week prior b. 2 weeks prior c. The day of admission d. Only two or three days before

ANS: D The nurse should suggest the toddler be told only days before. School-age children can be given more time to prepare. Adolescents should be told as far in advance as possible.

10. What is the correct order for assessing vital signs in an infant to ensure the accuracy of measurements? a. Respiration, temperature, pulse b. Pulse, respiration, temperature c. Temperature, pulse, respiration d. Respiration, pulse, temperature

ANS: D The respiration is taken first on an infant before the child is disturbed, pulses are assessed next, and last the temperature is obtained.