Unit 4 Practice Exam

During the first 4 days of hospitalization, Eric, age 18 months, cried inconsolably when his parents left him, and he refused the staff's attention. Now the nurse observes that Eric appears to "settle in" and be unconcerned about seeing his parents. The nurse should interpret this as which of the following?

He may be experiencing detachment, which is the third stage of separation anxiety.

The nurse is caring for an 8-year-old boy who had abdominal surgery 24 hours ago. He is quiet and watching television. The nurse's observations suggest that he is not experiencing pain, but when he is given a pain-rating scale, he indicates that he is experiencing moderate pain. The nurse's actions should be based on which of the following?

If children's behavior appears to differ from the rating of pain, their pain rating should be believed.

Four-year-old Brian appears to be very upset by hospitalization. Which of the following is an appropriate intervention?

Let him know it is all right to cry.

Kyle, age 6 months, is brought to the clinic. His parent says, "I think he hurts. He cries and rolls his head from side to side a lot." This most likely suggests which of the following features of pain?

Location

Nonpharmacologic strategies for pain management:

May reduce pain perception.

Which of the following drugs is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?

Morphine

Physiologic measurements in children's pain assessment are:

Of limited value as sole indicator of pain.

When a preschool child is hospitalized without adequate preparation, the nurse should recognize that the child may likely see hospitalization as which of the following?

Punishment

Which of the following represents the major stressor of hospitalization for children from middle infancy throughout the preschool years?

Separation Anxiety

The nurse is caring for a child who has been receiving meperidine (Demerol) every 4 to 6 hours for postoperative pain control during the last 48 hours. The nurse observes that the child is becoming very agitated and has mild hand tremors. It has been 5 hours since the last dose of meperidine. The most appropriate nursing action is which of the following?

Stop giving meperidine, and notify practitioner.

A 10-year-old girl needs to have another IV started. She keeps telling the nurse, "Wait a minute," and, "I'm not ready." The nurse should recognize that:

This is normal behavior for a school-age child.

Ryan has just been unexpectedly admitted to the intensive care unit following abdominal surgery. The nursing staff has completed the admission process and Ryan's condition is beginning to stabilize. When speaking with the parents, the nurses should expect which of the following stressors to be evident on the family: Select all that apply. A) Unfamiliar environment B) Usual day night routine C) Strange smells D) Provision of privacy E) Inadequate knowledge of condition and routine.

Unfamiliar environment Strange Smells Inadequate knowledge of condition and routine

Which of the following is usually the greatest threat to the hospitalized adolescent?

Fear of altered body image

Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which of the following nursing interventions will help her most in her adjustment to the hospital?

Explain hospital schedules to her, such as mealtimes.

The nurse is caring for a child receiving IV 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 of the following?

Administer naloxone (Narcan).

The nurse is doing a prehospitalization orientation for Diana, age 7, who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is:

An appropriate part of the child's preparation.

The parents of a 4-month-old infant cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of a young infant?

Assign her to the same nurse as much as possible.

Which of the following factors is an important consideration in understanding the pain experience in children?

Children may not admit having pain.

Matthew, age 18 months, has just been admitted with croup. His parent is tearful and tells the nurse, "This is all my fault. I should have taken him to the doctor sooner so he wouldn't have to be here." Which of the following is appropriate in the plan of care for this parent who is experiencing guilt?

Clarify misconception about the illness.

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler would be which of the following?

Encourage parents to room in.