Chapter 21: Family-Centered Care of the Child During Illness and Hospitalization

16. Which of the following factors is an important consideration in understanding the pain experience in children? 1. Children cannot tell where they hurt. 2. Children may not admit having pain. 3. Narcotics are dangerous drugs for children. 4. Children's sensitivity to pain is less than that of adults.

ANS: 2 2. Children may not admit having pain to avoid an injection. With constant pain, children may not realize how much they are hurting and believe that adults will know how they are feeling.

7. Which of the following is usually the greatest threat to the hospitalized adolescent? 1. Fear of pain 2. Fear of altered body image 3. Separation from home and family 4. Restricted motor activity

ANS: 2 2. Injury, pain, disability, and death are viewed primarily in terms of how each affects the adolescents' views of themselves in the present. Any change that differentiates them from their peers is regarded as a major tragedy

22. 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? 1. Administer meperidine. 2. Administer naloxone (Narcan). 3. Stop giving meperidine, and notify practitioner. 4. Place intubation equipment at the bedside.

3. Meperidine should be used only for short-term (48-hour) pain management in healthy patients who have demonstrated unusual reactions with other opiates. The child is frequently checked for signs of toxicity, such as tremors of the outstretched hands, twitching or jerking, or increased agitation. If toxicity is suspected, the drug is stopped, the IV infusion maintained, and the practitioner notified immediately.

1. 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.) 1. Unfamiliar environment 2. Usual day night routine 3. Strange smells 4. Provision of privacy 5. Inadequate knowledge of condition and routine.

ANS: 1, 3, 5 Intensive care units, especially when the family is unprepared for the admission, are a strange and unfamiliar place. There are many pieces of unfamiliar equipment. The sights and sounds are much different from a general hospital unit. Also, with the child's condition being more precarious, it may be difficult to keep the parents updated and knowledgeable of what is happening.

15. Samantha, age 5 years, tells the nurse that she "needs a Band-Aid" where she had an injection. Which of the following is the best nursing action? 1. Apply a Band-Aid. 2. Ask her why she wants a Band-Aid. 3. Explain why a Band-Aid is not needed. 4. Show her that the bleeding has already stopped.

ANS: 1 1. Children at this age group still fear that their insides may leak out at the injection site. Provide the Band-Aid.

13. Four-year-old Brian appears to be very upset by hospitalization. Which of the following is an appropriate intervention? 1. Let him know it is all right to cry. 2. Give him time to gain control of himself. 3. Show him how other children are cooperating. 4. Tell him what a big boy he is to be so quiet.

ANS: 1 1. Crying is an appropriate behavior for the upset preschooler. The nurse provides support through physical presence.

27. 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? 1. Clarify misconception about the illness. 2. Explain to parent that the illness is not serious. 3. Encourage parent to maintain a sense of control. 4. Assess further why parent has excessive guilt feelings.

ANS: 1 1. Guilt is a common response of a parent when a child is hospitalized. They may blame themselves for the child's illness or for not recognizing it soon enough. The nurse should clarify the nature of the problem and reassure the parent that the child is being cared for..

3. 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? 1. Punishment 2. Threat to child's self-image 3. An opportunity for regression 4. Loss of companionship with friends

ANS: 1 1. If a toddler is not prepared for hospitalization, a typical preschooler fantasy is to attribute the hospitalization to punishment for real or imagined misdeeds.

21. Nonpharmacologic strategies for pain management: 1. May reduce pain perception. 2. Make pharmacologic strategies unnecessary. 3. Usually take too long to implement. 4. Trick children into believing they do not have pain.

ANS: 1 1. Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics

14. 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 will help her most in her adjustment to the hospital? 1. Explain hospital schedules to her, such as mealtimes. 2. Use terms, such as "honey" and "dear," to show a caring attitude. 3. Explain when parents can visit and why siblings cannot come to see her. 4. Orient her parents, because she is young, to her room and hospital facility.

ANS: 1 1. School age children need to have control of their environment. The nurse should offer explanations or prepare the child for those experiences that are unavailable.

1. Which of the following represents the major stressor of hospitalization for children from middle infancy throughout the preschool years? 1. Separation anxiety 2. Loss of control 3. Fear of bodily injury 4. Fear of pain

ANS: 1 1. The major stress for children from infancy through the preschool years is separation anxiety, also called anaclitic depression. This is a major stressor of hospitalization.

25. 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? 1. Administer naloxone (Narcan). 2. Discontinue IV infusion. 3. Discontinue morphine until child is fully awake. 4. Stimulate child by calling name, shaking gently, and asking to breathe deeply.

ANS: 1 1. The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine.

12. Greg, age 2 years, was admitted to the pediatric unit yesterday. His parents are making plans to visit as often as possible during his hospitalization. Greg's parents complain to the nurse that the child "cries, screams, and throws himself" whenever they leave the hospital to eat. The nurse should do which of the following? 1. Explain that his behavior is a normal response to hospitalization. 2. Explain that this behavior will diminish in a few days. 3. Encourage the parents not to leave the child's room. 4. Encourage the parents to leave when the child is asleep.

ANS: 1 1. The nurse should reassure the parents that this is a normal response to hospitalization and separation from family.

5. 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: 1. This is normal behavior for a school-age child. 2. This behavior is usually not seen past the preschool years. 3. The child thinks the nurse is punishing her. 4. The child has successfully manipulated the nurse in the past.

ANS: 1 1. This school-age child is attempting to maintain control. The nurse should provide the girl with structured choices about when the IV will be inserted.

10. An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler would be which of the following? 1. Provide for privacy. 2. Encourage parents to room in. 3. Explain procedures and routines. 4. Encourage contact with children of the same age.

ANS: 2 2. A toddler experiences separation anxiety secondary to being separated from the parents. To avoid this, the parents should be encouraged to room in as much as possible.

9. Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse overhears her school-age siblings tell her, "We are sick of Mom always sitting with you in the hospital and playing with you . . . it isn't fair that you get everything and we have to stay with the neighbors." Which of the following is the nurse's best assessment of this situation? 1. The siblings are immature and probably spoiled. 2. Jealousy and resentment are common reactions to the illness/hospitalization of a sibling. 3. Family has ineffective coping mechanisms to deal with chronic illness. 4. The siblings need to better understand their sister's illness and needs.

ANS: 2 2. Siblings experience loneliness, fear, and worry, as well as anger, resentment, jealousy, and guilt. The siblings experience stress equal to that of the hospitalized child.

23. Which of the following drugs is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? 1. Codeine 2. Morphine 3. Methadone 4. Meperidine

ANS: 2 2. The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl

24. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply: 1. TAC (tetracaine/adrenalin/cocaine) 15 minutes before procedure. 2. Transdermal fentanyl (Duragesic) "patch" immediately before procedure. 3. EMLA (eutectic mixture of local anesthetics) 1 hour before procedure. 4. EMLA (eutectic mixture of local anesthetics) 30 minutes before procedure.

ANS: 3 3. EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture.

26. Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her "a lot of new toys, because she will be in the hospital." The nurse's reply should be based on an understanding of which of the following? 1. New toys make hospitalization easier. 2. New toys are usually better than older ones for children of this age. 3. At this age, children often need the comfort and reassurance of familiar toys from home. 4. Buying new toys for a hospitalized child is a maladaptive way to cope with parental guilt.

ANS: 3 3. Parents should bring favorite items from home to be with the child. Young children associate inanimate objects with people who are significant in their lives. The favorite items will provide comfort and reassurance to the child. Since the parents left the objects, the preschooler knows the parents will return.

2. 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? 1. He has successfully adjusted to the hospital environment. 2. He has transferred his trust to the nursing staff. 3. He may be experiencing detachment, which is the third stage of separation anxiety. 4. Because he is "at home" in the hospital now, seeing his mother frequently will only start the cycle again.

ANS: 3 3. These are the behavior manifestations of the separation anxiety phase of detachment. Superficially it appears that the child has adjusted to the loss.

17. The nurse is caring for a 6-year-old girl who had surgery 12 hours ago. The child tells the nurse that she does not have pain, but a few minutes later tells her parent that she does. Which of the following should be nurse consider when interpreting this? 1. Truthful reporting of pain should occur by this age. 2. Inconsistency in pain reporting suggests that pain is not present. 3. Children use pain experiences to manipulate their parents. 4. Children may be experiencing pain even though they deny it to the nurse.

ANS: 4 4. Children may deny pain to the nurse because they fear receiving an injectable analgesic or because they believe that they deserve to suffer as a punishment for a misdeed. They may refuse to admit pain to a stranger, but readily tell a parent.

8. The most common initial reaction of parents to illness or injury and hospitalization in their child is which of the following? 1. Anger 2. Fear 3. Depression 4. Disbelief

ANS: 4 4. Disbelief is the most common initial response of parents. This is especially true if the illness is sudden and serious.

20. Physiologic measurements in children's pain assessment are: 1. The best indicator of pain in children of all ages. 2. Essential to determine whether a child is telling the truth about pain. 3. Of the most value when children also report having pain. 4. Of limited value as sole indicator of pain.

ANS: 4 4. Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize.

19. 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? 1. Type 2. Severity 3. Duration 4. Location

ANS: 4 4. The child is displaying a local sign of pain. Rolling the head from side to side and pulling at ears are indicative of pain in the ear.

11. 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? 1. Place her in a room away from other children. 2. Tell the parents that frequent visiting is unnecessary. 3. Assign her to different nurses so she will have varied contacts. 4. Assign her to the same nurse as much as possible.

ANS: 4 4. The infant is developing a sense of trust. This is accomplished by the consistent care, loving, care by a nurturing person. If the parents are unable to visit, then the same staff nurses should be used as much as possible.

18. 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? 1. Physiologic responses are the best indicators of pain. 2. Children's behavior is a better indicator of pain than their rating of pain. 3. School-age children as young as 8 years do not rate pain very accurately. 4. If children's behavior appears to differ from the rating of pain, their pain rating should be believed.

ANS: 4 4. The pain rating should be believed. Children vary widely in their behavior responses to pain. This response is affected by the child's coping style, culture, and linguistic abilities.

6. A spinal tap must be done on a 9-year-old boy. While waiting in the treatment room, the nurse observes that he seems composed. When the nurse asks him if he wants his mother to stay with him, he says, "I am fine." Which of the following is the best interpretation of this situation? 1. Child is unusually brave. 2. Child has learned that support doesn't help. 3. School-age children do not usually want a parent present during the procedure. 4. School-age children often do not request support, even though they need and want it.

ANS: 4 4. The school-age child's visible composure, calmness, and acceptance often mask their inner longing for support. It is especially important to be aware of nonverbal cues such as facial expression, silence, or lack of activity. Usually when someone identifies the unspoken messages, the child will readily accept support.

28. 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: 1. Unnecessary. 2. The surgeon's responsibility. 3. Too stressful for a young child. 4. An appropriate part of the child's preparation.

ANS: 4 4. This is a necessary part of preoperative preparation. If the child wakes and is not prepared for the inability to speak, she will be even more anxious

4. Because of their striving for independence and productivity, which age group of children is particularly vulnerable to events that may lessen their feeling of control and power? 1. Infant 2. Toddler 3. Preschooler 4. School-age child

ANS: 4 4. When a child is hospitalized, the altered family role, physical disability, loss of peer acceptance, lack of productivity and inability to cope with stress usurps individual power and identity. This is especially detrimental to school-age children, who are striving for independence and productivity and are now experiencing events that lessen their control and power.