Chapter 33: Caring for Children in Diverse Settings

While the nurse is admitting a 5-year-old client, the caregiver asks, "What can I do to make my child feel secure? This is our first hospitalization." Which nursing response is best?

"You staying with your child will provide the most security." Rationale: The nurse would recommend the caregiver stay with the child. Rooming-in minimizes the hospitalized child's separation anxiety and fears. One of the biggest advantages of rooming-in is the measure of security the child feels. Telling the caregiver to bring the child's favorite toy is okay; however, this does not address the concern of security. Stating "not to worry" and not addressing the caregiver's concerns at this time are not appropriate forms of therapeutic communication from the nurse. There is no indication the child is unstable, so the nurse could stop long enough to speak to the caregiver.

The nurse is caring for a technology-dependent school-aged child in his home. Which action best builds a trusting relationship?

Discussing care and treatment with the parent and child together. Rationale: To build a trusting relationship with the family, the nurse must remember the child is both the client and a family member. He needs to be included in all discussions. Encouraging parents to join a support group and talking with the sibling of the ill child who feels ignored are important and supportive activities. Changing the date and time of a therapy session to fit the family schedule is a case management activity. These are important elements of family-centered home care, but are not meant specifically to build trust.

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

"Let's see who can blow these cotton balls off the table first." Rationale: 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.

The school nurse has contacted the mother of a 6-year-old child who has recently been diagnosed with diabetes. The nurse has asked the child's mother to help her develop an Individualized Health Plan (IHP). The child's mother reports she is busy and asks what this will entail. What information can be provided by the nurse?

"This plan will outline the health needs of your child." Rationale: The nurses in the school setting develop Individualized Health Plans (IHPs). An IHP formalizes the plan of support for a student with complex health care needs. It is a written agreement developed as part of an interdisciplinary collaboration of school staff along with the student, the student's family, and the student's health care provider. The plan describes the student's needs and how the school plans to meet these needs. The nurse plays a critical role in developing these plans. The nurse will use the nursing process and then, based on the nursing assessment and diagnosis, will develop goals and interventions to ensure that the child's needs are being met.

A preschool teacher calls the hospital and wants to introduce the concept of a hospital to her preschool class in case they ever get sick and need to be admitted. What resources could the child life specialist provide for this group to aid in their learning? Select all that apply.

-Provide a room for the class with hospital gowns, masks and equipment used on children. -Tour the hospital, including the playrooms on the pediatric floors. -Let the children lie in the beds, use the call lights and practice being a patient. Rationale: Preschoolers are curious and love to manipulate the equipment used at the hospital. By making admission to the hospital less frightening for them, they will adjust better if they have to be admitted. Mentioning people not leaving the hospital indicates they died; this is scary to the children and inappropriate for this session. Children are never allowed to play with needles or syringes - it is too dangerous.

The nurse is documenting the child's intake. The child ate 4 cups of ice during this shift. How many cups of fluid did the child ingest?

2 cups of fluid Rationale: Ice is approximately equivalent to half the same amount of water, which in this instance would be 2 cups of fluid.

The nurse is caring for a 6-year-old client who is prescribed to cough and deep breathe following surgery. Which nursing action is best for this client?

Blow a pinwheel and bubbles with the child. Rationale: The nurse will have the child blow bubbles and a pinwheel to accomplish the prescription as these actions are most like play. These actions will encourage and engage the child and are likely to be accepted and even enjoyed. All of the measures have potential to get the child to cough and deep breathe to some extent, but blowing bubbles and a pinwheel is best for the client's age.

A nurse is admitting a 7-year-old child to the pediatric unit of the hospital. While the nurse is showing the child and parents the room and explaining where things are, the child becomes upset and frightened. What is the best action by the nurse?

Go slowly with the acquaintance process. Rationale: The child who reacts with fear to well-meaning advances and who clings to the caregiver is telling the nurse to go slowly with the acquaintance process. The child who knows that the caregiver may stay is more quickly put at ease. To provide security for the child and to provide family-centered care, it is the responsibility of the nurse to form good partnerships with families. Asking the family to leave the room in this situation would only frighten the child more. The nurse should never provide false reassurance. Telling the child there is nothing to be afraid of or nothing will hurt him or her are promises the nurse cannot make to the child.

Caregivers of a hospitalized toddler are being given safety instructions upon admission to the pediatric floor. Which action by the caregiver would be most important to the toddler's safety?

Keep the crib side rails up at all times. Rationale: Many toddlers are climbers and are always curious. So side rails must be kept fully up at all times, except when direct care is being provided. If side rails are down, the nurse or caregiver must keep a hand firmly on the child. Providing a call button to a toddler is not a good idea since the child will be pushing it all the time. Beds and cribs are kept at the lowest setting to minimize the possibility of injury if the child does fall out.

The toddler needs elbow restraints to keep his hands away from a facial wound. What will the nurse do to best ensure their safe use?

Remove one restraint at a time on a regular basis to check for skin irritation. Rationale: Removing one restraint at a time provides for control of both hands. A long-sleeve shirt under the elbow restraints also protects the skin, and is a better choice than lotion since lotion will soften the skin and not be protective. The restraints should not extend into the axilla. Movement would create pressure and irritation. The parent can help monitor the restraints, but the nurse is responsible for the safety of their use.

The hospital nurse is providing discharge instructions to the caregivers of a 10-year-old child with a new prosthetic limb. Which finding will cause the nurse to contact the primary health care provider?

The child is being discharged home with the caregiver. Rationale: The nurse would question the child with a new prosthetic limb being sent home immediately from the hospital. Sending the child to a rehabilitation unit is best to facilitate usage of the prosthetic limb. The care in a rehabilitation unit involves an interdisciplinary approach that assists the child to reach his or her potential and achieve developmental skills. A diagnosis of hypothyroidism in infancy would not be concerning to the use of a prosthetic. The WBC and blood pressure are both within normal range for a client of this age. The normal WBC is 5,000 to 10,000 mm3 (5 to 10 x 109/L) and blood pressure range is 95-120/55-76 mm Hg.

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 Rationale: 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.

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 Rationale: 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.

The nurse is caring for a child admitted to the hospital. The child's mother had to go home to take care of her other children. The child has become quiet, is not crying and is refusing to eat. The nurse would document the child is in which stage of separation anxiety?

second stage Rationale: In the second phase of separation anxiety, the child displays hopelessness by withdrawing from others, becoming quiet without crying, and exhibiting apathy, depression, lack of interest in play and food, and overall feelings of sadness. In the first phase, the child reacts aggressively to this separation and exhibits great distress by crying, expressing agitation, and rejecting others who attempt to offer comfort. In the third phase of separation anxiety, the child forms coping mechanisms to protect against further emotional pain. There is no fourth stage of separation anxiety.

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." Rationale: One factor in how children deal with hospitalization is the amount of preparation and the type of preparation they have been given prior to being hospitalized. A child's lack of understanding and experience with illness, hospitals, and hospital procedures increases his or her anxiety. Anything parents can do to prepare the child will decrease this anxiety. Families are encouraged to help children develop a positive attitude about hospitals from an early age. The family should avoid negative attitudes about hospitals and should help the child understand that not all experiences will be good. 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. Anytime the child can visually see the hospital and physically touch furniture, equipment, etc. a positive experience can occur. Showing pictures in a book, seeing posters, and talking about the experience are also effective if a tour of the hospital is not available, but these do not replace the actual experience.

The nurse is developing a preoperative plan of care for a 2-year-old toddler. The nurse will focus attention to which of the toddler's age-related fears?

separation anxiety Rationale: A toddler is most likely to develop anxiety and fears due to separation from the parents. Trust is needed by infants. A loss of control and a loss of independence are fears experienced by an preschool-age clients through adolescents.

The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will the nurse and specialist prioritize to assist this child in better understanding what will be happening in the treatment of the cancer?

therapeutic play Rationale: Therapeutic play is a play technique used to help the child better understand what will be happening to him or her in a specific situation. For instance, the child who will be having an IV started before surgery might be given the materials and encouraged to "start" an IV on a stuffed animal or doll. By observing the child, you can often note concerns, fears, and anxieties the child might express. Therapeutic play helps the child express feelings, fears, and concerns. The other types of play will not accomplish this goal.

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

therapeutic play Rationale: Play is a very important part of nursing care. Therapeutic play is nondirected and focuses on helping the child cope with feelings and fears. It helps the child deal with the challenges of illness and hospitalization. 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. Emotional play or play therapy is play that allows the child to act out stressors or dramatize real-life stressors. For example, to relieve anger a child may be given something to pound. Interactive play is where children play together cooperatively. Parallel play is where toddlers play side by side but not together.

A 6-year-old with leukemia is placed on reverse isolation. What nursing actions could prevent depression and loneliness in this client? Select all that apply.

-Spend extra time to talk while in the room. -Read a story while in the room. -Play a game while in the room. Rationale: A child on isolation is subject to loneliness, which can be prevented by arranging to spend extra time in the room during treatments. Also, while in the room the nurse might read a story, play a game, or just talk to the child. Quickly exiting the room and providing cluster care will increase social isolation and may make the child feel punished.

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. Rationale: 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. Teaching the therapeutic plan is important, but it has to be done on the level of the child's and caregivers' knowledge and build on what they already know. The child going to surgery will be NPO, but the nurse needs to know on what level to teach the child the reason for this.