Chapter 22: Health Care Adaptations for the Child and Family, Chapter 23: The Child with a Sensory or Neurological Condition, Chapter 21: The Child's Experience of Hospitalization, Chapter 23: The Child with a Sensory or Neurological Condition

12. A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Akinetic c. Myoclonic d. Complex partial

ANS: A Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds. DIF: Cognitive Level: Analysis REF: p. 545, Table 23-2 OBJ: 12 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse explains that a common treatment for amblyopia is: a. patching the good eye to force the brain to use the affected eye.

ANS: A Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors. DIF: Cognitive Level: Knowledge REF: p. 536 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. The nurse explains that a common treatment for amblyopia is: a. patching the good eye to force the brain to use the affected eye. b. patching the affected eye to allow the refractory muscles to rest. c. using glasses that will slightly blur the image for the good eye. d. using corticosteroids to treat inflammation of the optic nerve.

ANS: A Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors. DIF: Cognitive Level: Knowledge REF: p. 536 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. The nurse would suspect: a. meningitis. b. Reye's syndrome. c. brain tumor. d. encephalitis.

ANS: C The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops? a. Up and back

ANS: A For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

13. An adolescent has just had a generalized seizure and collapsed in the school nurse's office. The nurse should call 911 if the student: a. has a seizure lasting more than 5 minutes. b. is sleepy and lethargic after the seizure. c. fell at the onset of the seizure. d. is confused and has slurred speech after the seizure.

ANS: A If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency. DIF: Cognitive Level: Analysis REF: p. 545, Table 23-2 OBJ: 12 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

18. The assessment finding that should be reported immediately if observed in a child with meningitis is: a. irregular respirations. b. tachycardia. c. slight drop in blood pressure. d. elevated temperature.

ANS: A Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure.

How often should a child who has a continuous intravenous infusion should be assessed? a. Hourly

ANS: A The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

26. The nurse suggests to parents that they use the outpatient surgical center for their child's upcoming surgery. What advantage(s) does this type of facility have to offer? (Select all that apply.) a. Lower cost b. Less incidence of health care-associated infections c. Reduction of parent-child separation d. Ample time for recuperation at the facility e. Decreased emotional impact of illness

ANS: A, B, C, E All options listed are advantages of outpatient services with the exception of recuperating at the facility.

39. Which are appropriate interventions to improve a child's hospitalization, regardless of age? Select all that apply. A. Provide recuperation at home when possible. B. Provide a cheerful, casual atmosphere. C. Provide a flexible schedule. D. Provide a roommate who is age-appropriate. E. Provide for rooming in for parents. F. Provide activities that are developmentally appropriate.

ANS: A, B, C, E, F Rationale: It is not best practice to provide a roommate for hospitalized children. The other interventions listed provide benefit to the hospitalized child.REF: Page 475

Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all that apply.) a. Insulin b. Digoxin d. Calcium salts e. Anticoagulants

ANS: A, B, D, E Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a licensed nurse prior to administration.

Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure d. That the document must be signed and witnessed e. That information was given

ANS: A, B, D, E The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed.

28. What information will the nurse include when taking a developmental history? (Select all that apply.) a. Previous experience with hospitalization b. Cultural needs c. History of illness d. Allergies e. Child's nickname

ANS: A, B, E The developmental history has information about the child and the child's developmental and cultural needs and personal preferences. The information relative to history of illness or allergies would be covered in the medical history.

29. The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are appropriate for the nurse to implement? (Select all that apply.) a. Model desired behavior. b. Instruct patient not to yell. c. Use distractions. d. Explain the procedure in detail. e. Encourage the child to ask questions.

ANS: A, C Whenever possible the parent should be involved in the preparation for and initiation of a treatment or procedure, and the child should be prepared according to his or her developmental level. For a toddler, model the behavior desired (i.e., opening the mouth), tell the child it is okay to yell if the treatment or procedure is uncomfortable, and use distractions. Explaining the procedure in detail and encouraging questions are appropriate interventions for an older child.

2. A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago. What does this behavior suggest? a. The toddler feels abandoned by his mother. b. The child still has not adjusted to his hospitalization. c. The child is not separated from his mother often. d. There is a poor mother-child bond.

ANS: A Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization are obvious.

Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant? a. Mummy

ANS: A A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.

.2. The nurse determines a mother understands instructions about administering an oral antibiotic for otitis media when the mother verbalizes that she will: d. administer prescribed doses until all the medication is used.

.ANS: D Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated. DIF: Cognitive Level: Application REF: p. 532, Nursing Tip OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

.2. The nurse determines a mother understands instructions about administering an oral antibiotic for otitis media when the mother verbalizes that she will: a. continue using the medication until symptoms are relieved. b. share the medicine with siblings if their symptoms are the same. c. give the medication with a glass of milk. d. administer prescribed doses until all the medication is used.

.ANS: D Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated. DIF: Cognitive Level: Application REF: p. 532, Nursing Tip OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

After instilling nose drops, the nurse will keep the infant in the head down position for at least _________ seconds.

ANS: 30 The retained position for 30 seconds to 1 minute allows the nose drops to enter deeply into the nostril.

The order reads, "Give ampicillin oral suspension 400 mg PO every day." The vial reads, "Ampicillin 125 mg/5 mL." The nurse will give a dose of ______ mL.

ANS: 16

19. An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a fractured femur. What does the nurse realize immobilization in this age-group can generate feelings of in planning care of this child? a. Loss of control b. Altered body image c. Shame and guilt d. Fear of bodily harm

ANS: A Forced dependency in the hospital, such as immobilization, can result in a feeling of loss of control and loss of security.

7. A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his favorite bottle. What is the most likely reason for this behavior? a. He is dealing with the anxiety of hospitalization by regressing. b. He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital. c. He is attempting to refocus the attention of the adults around him to avoid further painful procedures. d. He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they have mastered them.

ANS: A Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital.

23. The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention is appropriate for the nurse to implement? a. Involve the parents. b. Provide a simple explanation to the child. c. Let the child examine the equipment. d. Suggest coping techniques.

ANS: A It is appropriate to involve the parents when performing a procedure on an infant. Providng a simple explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate interventions for an infant.

41. What is the drug of choice for the relief of mild to moderate pain in infants and children? A. Acetaminophen B. Ibuprofen C. Fentanyl D. Naloxone

ANS: A Rationale: Acetaminophen is commonly used for the relief of mild to moderate pain in infants and children

31. What are the stages of separation anxiety in the toddler? A. Protest, despair, and denial B. Denial, dependence, and submission C. Protest, sadness, and despair D. Despair, anxiety, and regression

ANS: A Rationale: The major tasks of adolescence include establishing an identity, separating from family, initiating intimacy, and developing career choices for economic independence. Erikson identifies the major task of this group as identity versus role confusion. Emancipation is a critical element in the establishment of identity.

18. What statement by the parent of a hospitalized toddler leads the nurse to determine the parent understands a hospitalized toddler's need for transitional objects? a. "This stuffed animal makes him feel secure." b. "He insisted on bringing this dirty old blanket with him." c. "I'm going to buy him a big stuffed animal from the gift shop." d. "I'd like to get him some toys from the playroom."

ANS: A The use of a transitional object such as a blanket or a favorite toy promotes security.

21. The nurse shares the information and timelines recorded on the interdisciplinary outline of care for a child. What is this document? a. Clinical pathway b. Comprehensive nursing care plan c. Holistic care approach d. Incorporated cost analysis

ANS: A This document is the clinical pathway, which is a broad outline of interdisciplinary plan of care with specific timelines.

25. What will the nurse include when documenting the discharge of a pediatric patient? (Select all that apply.) a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation e. Instructions that were given to physician

ANS: A, B, C, D Information that should be included in the discharge note include time of discharge, adults accompanying the child and relationship to child, condition of the child, and method of transportation. It should also be documented that instructions were given to parents.

28. What intervention(s) would the nurse caring for a child with infectious meningitis include? Select all that apply. a. Isolation precautions b. Provision of dimly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions

ANS: A, B, C, D, E All elements of nursing care listed in the options would be part of comprehensive care of a child with meningitis.

26. The nurse cautions parents that hearing impairment can affect which aspect(s) of the child's development? Select all that apply. a. Speech clarity b. Language development c. Emotional stability d. Personality development e. Academic achievement

ANS: A, B, C, D, E All the options are areas in which a hearing impairment could interfere with normal development.

29. When documenting a grand mal seizure, what would the nurse include? Select all that apply. a. Presence of incontinence b. Current dose of antispasmodic medication c. Activity level prior to and following seizure d. Level of consciousness following seizure e. Length of seizure

ANS: A, C, D, E Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.

27. What are the basic fears of a young child being hospitalized? (Select all that apply.) a. Separation b. Permanent scarring c. Pain d. Cost e. Body intrusion

ANS: A, C, E Small children all share the same basic fears relative to hospitalization, which are separation from family, pain, and body intrusion or mutilation.

What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all that apply.) a. Age d. Distance to travel e. Level of consciousness

ANS: A, D, E The means by which the child is transported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel.

8. A nurse encourages a school-age child to draw a picture after a painful procedure. What is the best rationale for this nursing intervention? a. Attempting to re-establish rapport b. Providing a way for the child to express his feelings c. Encouraging quiet play d. Distracting the child from thinking about the pain

ANS: B After treatments, the nurse should encourage children to draw and talk about their drawings or to act out their feelings through puppet play.

16. When a 2-year-old returns to her hospital room following a diagnostic procedure, her parents are not available, and the child is crying loudly. Which technique is most appropriate to alleviate the child's distress? a. Rock the child gently to sleep. b. Play with the child using pop-up toys. c. Role play with the child to act out her feelings. d. Ask the child to draw a picture about her feelings.

ANS: B Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help reduce anxiety and pain.

13. The mother of a hospitalized toddler states, "He cries when I visit. Maybe I should just stay away." What is the nurse's best response? a. "Perhaps you are right. He only gets upset when you have to leave." b. "It is important that you are here. This is a common reaction in children when they are separated from their parents." c. "It might be easier for your child if you would stay with him, but this decision is up to you." d. "We take good care of him and he seems fine when you are not here."

ANS: B During the second stage of separation anxiety (despair), the child is quiet, is not crying, and is sad and depressed. The child will revert to protest when the parent arrives for a visit.

20. The nurse explains to the parents of a hospitalized child that their child will receive fentanyl for an upcoming procedure. What advantage of fentanyl will the nurse explain? a. It is specifically designed for children. b. It has a rapid onset. c. It is nonaddicting. d. It has a long duration.

ANS: B Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.

42. What statement about discharge planning for the pediatric patient is true? A. Continues after discharge B. Begins upon admission C. Is initiated by the pediatrician's office D. Begins when the parents are ready

ANS: B Rationale: Preparation for the patient's discharge ideally begins on admission, because the goal of hospitalization is to return a healthier and happier child to the parents

40. A hospitalized toddler requests a bottle for his juice, although he has been drinking from a cup at home. What instructions should the nurse provide to the parents? A. Encourage the child to use a straw. B. Praise appropriate behavior and ignore regressions. C. Redirect him and remind him he is a big boy who drinks from a cup. D. Distract him and provide the juice in a cup.

ANS: B Rationale: Regression should not be punished. Nurses can guide parents to praise appropriate behavior and ignore regressions. When the child is free of the stress that caused the regression, praise will motivate the achievement of appropriate behavior.

33. The best way to minimize separation anxiety in the hospital infant is to A. Explain routines carefully B. Encourage parents to room-in C. Provide age-appropriate roommate D. Provide an age appropriate toy

ANS: B Rationale: Rooming-in is highly desirable. When rooming-in is impossible, consistent caregivers should be assigned to care for the child and the parents.

34. Which statement by the parent of a hospitalized 4 year-old child indicated an understanding of the child's needs? A. "I am going to buy him a box of new toys to keep him busy while in the hospital." B. "I am going to bring some of his favorite toys from home for him to play with while he's in the hospital." C. "I'm glad there is a television in the room for him to watch all day." D. "I will stay every day and till he falls asleep and then I will go home."

ANS: B Rationale: The use of a transitional object, such as a blanket or a favorite toy from home, promotes security.

1. Which child would have the most difficulty in coping with separation from parents because of hospitalization? a. 3-month-old child b. 16-month-old child c. 4-year-old child d. 7-year-old child

ANS: B Separation anxiety occurs after age 6 months and is most pronounced in the toddler.

15. Which nursing action would facilitate rapport with a child and the child's parents during the admission process? a. Direct the parents to undress the child. b. Answer questions in a calm and matter-of-fact way. c. Perform assessments and ask questions as quickly as possible. d. Express concern about the seriousness of the child's condition.

ANS: B The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless of the child's condition.

3. Which statement best corresponds to a preschooler's understanding of hospitalization? a. "A germ made me get sick." b. "I got sick because I was mad at my brother." c. "My tonsils are sick and they have to come out." d. "I have a cast because I broke my leg."

ANS: B The preschooler may feel guilty, particularly if an accident happens as a result of mischief on his or her part.

10. The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around 12:00 PM. The next morning, the child asks the nurse, "When is my mommy coming?" What is the nurse's best response? a. "Your mommy will be here around noon." b. "Your mommy will be here when you have lunch." c. "Mommy will be here very soon." d. "Your mommy is coming in 4 hours."

ANS: B The toddler and preschooler do not understand time yet. They understand time relationships through activities in their experience, such as naptime and mealtimes.

The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide? b. 1.4

ANS: B This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an infant.

The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention? b. School-age child with widening pulse pressure

ANS: B A widening pulse pressure can indicate increased ICP; therefore, it is the priority. An axillary temperature of 99 F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments.

What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant? b. Apical

ANS: B Apical pulses are advised for children under age 5 years.

Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury? b. Diapers and wipes are stacked at the foot of the crib.

ANS: B Disposable diapers and supplies must be kept out of the infant's reach to prevent accidental suffocation.

14. When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing action would be to: a. guide the child to the floor if the child is standing, and then go for help. b. move objects out of the child's immediate area. c. stick a padded tongue blade between the child's teeth. d. manually restrain the child.

ANS: B During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury. DIF: Cognitive Level: Application REF: p. 545, Table 23-2 OBJ: 12 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

What emergency action should be implemented for airway obstruction in the infant? b. Five back blows followed by five chest thrusts

ANS: B Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the infant.

15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. After a generalized tonic-clonic seizure, the nurse would expect that the child might be: a. restless. b. sleepy. c. nauseated. d. anxious.

ANS: B Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness. DIF: Cognitive Level: Analysis REF: p. 544, Table 23-2 OBJ: 12 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B to protect against: a. encephalitis. b. influenza. c. bacterial meningitis. d. otitis media.

ANS: B H. influenza type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.

24. In caring for a 3-year-old with a head injury, the nurse would report the probability of increasing intracranial pressure (ICP) based on the assessment of: a. temperature increase from 37.2 C (99 F) to 37.7 C (100 F). b. increase in blood pressure with an attendant decrease in pulse. c. increase in respirations. d. equilateral pupils.

ANS: B Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.

6. The school nurse would suspect strabismus when the child: b. covers one eye to read the chalkboard.

ANS: B Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, it is too vague to point suspicion to any disorder. DIF: Cognitive Level: Analysis REF: p. 535 OBJ: 4 TOP: Strabismus KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. The school nurse would suspect strabismus when the child: a. has a reddened sclera in one eye. b. covers one eye to read the chalkboard. c. complains of a headache. d. has copious tears while watching TV.

ANS: B Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, it is too vague to point suspicion to any disorder. DIF: Cognitive Level: Analysis REF: p. 535 OBJ: 4 TOP: Strabismus KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will the nurse maintain for this patient? b. Supine

ANS: B The adolescent may avoid post-lumbar puncture headache by lying flat for some time.

The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions? b. "I clean the perineum from front to back with an antiseptic wipe before I urinate."

ANS: B To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

A 4-year-old child asks tearfully if the IM injection will hurt. What is the nurse's most effective response? b. "Yes. It will sting a little."

ANS: B Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

An infant's dry diaper weighs 2.5 g. The wet diaper weighs 47 g. How would the nurse record the infant's urine output? b. 44.5 mL

ANS: B Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one milliliter of output. 47 - 2.5 = 44.5 g = 44.5 mL of urine.

A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F. Which actions will the nurse implement? (Select all that apply.) b. Administer acetaminophen as ordered. c. Assess skin turgor. e. Assess level of consciousness.

ANS: B, C, E When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.

25. Why would the pediatric nurse suspect the probability of an ear infection in a 6-month-old child? Select all that apply. a. Hypersensitivity to noise b. Irritability c. Reddened ear canal d. Rolls head from side to side e. Temperature of 39.4 C (103 F)

ANS: B, D, E Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.

24. The pediatric nurse is caring for child that weighs 15 kilograms and calls the physician for an order for Acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates ordering? a. 100 mg b. 150 mg c. 225 mg d. 250 mg

ANS: C Acetaminophen is commonly used for the relief of mild to moderate pain in infants and children. The maximum dose is 15 mg/kg/dose for infants and children, with a maximum of 5 doses in 24 hours.

22. The anxious parent asks if there is a danger of her 2-year-old child becoming addicted to the opioid pain reliever. What is the nurse's most helpful response? a. "Although this drug is addictive, the doctor monitors the dose very carefully." b. "Don't worry. Addicted children are very easy to wean off the drug." c. "Addiction is rare in children when opiates are given for pain." d. "Addictive behaviors are easy to assess. The drug will be stopped if that happens."

ANS: C Addiction is rare in children.

5. The nurse must make a room assignment for a 16-year-old with cystic fibrosis. Which roommate would be the most appropriate for this patient? a. A 4-year-old child who had an appendectomy b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis c. A 15-year-old with type 1 diabetes mellitus d. To assign the adolescent to a private room

ANS: C Adolescents usually do better in rooms with one or more roommates than in single rooms. The adolescent would do best with a roommate who is closest to his or her age and also lives with a chronic illness.

11. A 13-year-old girl has been hospitalized for the past week. When discussing the girl's feelings about her illness, what would the nurse expect the girl to express as her biggest concern? a. Invasive procedures b. Loss of control c. Appearance d. Separation from her boyfriend

ANS: C Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image.

14. What should the nurse, preparing to collect an admission history from parents who have recently emigrated from Russia, keep in mind? a. Eye-to-eye contact is considered disrespectful. b. Touching the child's head means the nurse is superior. c. Smiling is inappropriate in a serious situation. d. Staring is a sign of the nurse's rudeness.

ANS: C In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.

4. The parents of a hospitalized toddler are upset because she seems more interested in her toys when they come to visit her. In which stage of separation anxiety is the toddler? a. Protest b. Despair c. Denial d. Attachment

ANS: C In the stage of denial or detachment, the child appears to deny the need for the parents and becomes uninterested in their visits.

9. What is the best suggestion by the nurse when parents ask, "When is the best time to begin to prepare a 5-year-old for surgery and hospitalization?" a. "As soon as the surgery is scheduled" b. "About 2 weeks before surgery" c. "About 4 days before surgery" d. "On the night before admission to the hospital"

ANS: C Parents should prepare children for procedures and hospitalization a few days in advance.

32. Assessment of pain is considered a fifth vital sign to be documented by the nurse. The nurse understands that pain in infants? A. Cannot be reliably assessable B. Will not be remembered by the infant C. Can be assessed by observation of behavior D. Is usually caused by fear and anxiety

ANS: C Rationale: In infants, pain may be assessed according to a behavior scale that includes tightly closed eyes, clenched fists, and a furrowed brow.

35. A 4 year-old hospitalized child wets his bed. The parents tell the nurse and the child was completely toilet trained. What should the nurse understand? A. The parents are denying a problem exists. B. The child may be developmentally delays. C. The child may be experiencing regression. D. The child is probably "punishing" the parents.

ANS: C Rationale: Regression is the loss of an achieved level of functioning that previously had been successful to a past level of behavior.

10. The nurse caring for a 5-month-old with viral influenza suspects the development of Reye's syndrome when the child: a. has respirations drop from 18 to 14 breaths/min. b. goes to sleep after feeding. c. suddenly vomits without effort. d. develops a macular rash.

ANS: C A child with a viral infection is at risk for Reye's syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child that sleeps after eating is normal. DIF: Cognitive Level: Application REF: p. 540 OBJ: 9 TOP: Reye's syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

21. A child is brought to the emergency department after he fell and hit his head on the ground. The nursing assessment that suggests the child has a concussion is: a. sleepy but easily arousable. b. complaining of a stiff neck. c. cannot remember what happened to him. d. pupils react sluggishly to light.

ANS: C A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

8. The school nurse recognizes the cardinal sign of a hyphema when she assesses: a. opacity of the lens. b. a yellow-white reflex on the pupil. c. a dark-red spot in front of the iris. d. inflamed mucous membranes of the eyelids.

ANS: C A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury. DIF: Cognitive Level: Knowledge REF: p. 537 OBJ: N/A TOP: Hyphema KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse? c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.

ANS: C After confirmation of the child's identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

A parent tells the nurse, "I'm not sure how to give this medicine to my infant." How would the nurse teach the parent to best administer an oral suspension? c. Use an oral syringe and placing the medication in the side of the infant's mouth.

ANS: C An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is placed midway back, at the side of the mouth.

16. The nurse creating a teaching plan that includes the long-term administration of phenytoin (Dilantin) would state that: a. the medication should be given on an empty stomach. b. insomnia can be a significant side effect. c. gums should be massaged regularly to prevent hyperplasia. d. blood pressure should be closely monitored.

ANS: C Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day.

20. The nurse giving instructions for acute conjunctivitis would teach parents to: a. apply cool compresses to the affected eye several times a day. b. instill topical steroid eye drops for 1 week. c. clear drainage from the inner to the outer aspect of the eye. d. keep the eye patched until the inflammation resolves.

ANS: C Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).

5. The nurse planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes would include: c. avoiding getting water in the ears.

ANS: C Following a tympanostomy, care should be taken to avoid getting water in the ears. DIF: Cognitive Level: Comprehension REF: p. 532 OBJ: 2 TOP: Postoperative Care of Tympanostomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

5. The nurse planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes would include: a. keeping the infant flat after feeding. b. giving over-the-counter decongestants. c. avoiding getting water in the ears. d. cleaning the ear canal with cotton-tipped applicators.

ANS: C Following a tympanostomy, care should be taken to avoid getting water in the ears. DIF: Cognitive Level: Comprehension REF: p. 532 OBJ: 2 TOP: Postoperative Care of Tympanostomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

What factor does the nurse explain affects the infant's physiological response to medications? c. Immature kidney function

ANS: C Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of age.

19. The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated. The nurse recognizes this posture as: a. correct anatomical position. b. decorticate. c. decerebrate. d. opisthotonos.

ANS: C In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.

What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant? c. Apply a cloth diaper.

ANS: C Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left undiapered on a cloth pad.

9. The nurse is planning to teach parents about prevention of Reye's syndrome. What information would the nurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parents to have their children immunized against Reye's syndrome. c. Avoid giving salicylate-containing medications to a child who has viral symptoms. d. Get the child tested for Reye's syndrome if the child exhibits fever, vomiting, and lethargy.

ANS: C Prevention of Reye's syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms. DIF: Cognitive Level: Application REF: p. 539 OBJ: 9 TOP: Reye's syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed

ANS: C Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated. DIF: Cognitive Level: Analysis REF: p. 548 OBJ: 14 TOP: Cerebral Palsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Which intervention will the nurse implement when suctioning a tracheostomy? c. Apply suction for no more than 15 seconds.

ANS: C Suctioning should be limited to 15 seconds.

Why is a tympanic thermometer considered more accurate than other types of thermometers? c. The tympanic membrane shares circulation with the hypothalamus. .

ANS: C The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the hypothalamus share the same circulation.

The nurse is caring for a 4-year-old child. What will the nurse expect the child's daily urinary output to be? c. 600 to 700 mL

ANS: C The average daily excretion of urine for a 4-year-old child is 600 to 700 mL.

4. The best way for the nurse to communicate with a 10-year-old child who has a hearing impairment would be to: c. face the child and speak clearly in short sentences.

ANS: C The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality. DIF: Cognitive Level: Application REF: p. 533, Nursing Tip OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. The best way for the nurse to communicate with a 10-year-old child who has a hearing impairment would be to: a. use gestures and signs as much as possible. b. let the child's parents communicate for her. c. face the child and speak clearly in short sentences. d. recognize that the child's ability to communicate will be on a 6-year-old child's level.

ANS: C The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality. DIF: Cognitive Level: Application REF: p. 533, Nursing Tip OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

30. Parents are preparing their child for admission to the pediatric unit for minor surgery. What should they expect to see when visiting the pediatric unit? (Select all that apply.) a. Nurses wearing all white b. Formal atmosphere c. Availability of a playroom d. Dim lighting e. Colored bedding

ANS: C, E The children's hospital unit differs in many respects from adult divisions. The pediatric unit or hospital is designed to meet the needs of children and their parents. A cheerful, casual atmosphere helps to bridge the gap between home and hospital and is in keeping with the child's emotional, developmental, and physical needs. Nurses wear colorful uniforms, and colored bedspreads and wagons or strollers for transportation provide a more homelike atmosphere. The physical structure of the unit includes furniture of the proper height for the child, soundproof ceilings, and color schemes with eye appeal. Most pediatric departments include a playroom.

36. Which of the following can be a result of acetaminophen toxicity? A. Gastrointestinal distress B. Cerebral impairment C. Decreased urinary output D. Liver failure

ANS: D Rationale: Acetaminophen toxicity involves liver failure.

38. What pain indicator rated on a 1-to-10 scale can be used with nonverbal children? A. PICIC B. Wong-Baker scale C. Nomogram D. FLACC

ANS: D Rationale: The FLACC scale is a pain indicator that can be used with nonverbal children and is rated on a scale of 0 to 2 for each observation, with 10 being the highest level of pain.

37. The pediatric nurse is discharging a 3-year-old patient of Asian descent. When explaining the discharge instructions to the patient's parents, the nurse notices they are not making eye contact. What factor should be considered by the nurse to be accurate about this situation? A. The parents are not paying attention. B. The parents have a language barrier. C. The parents do not understand the information. D. The parents may consider eye contact to be disrespectful.

ANS: D Rationale: The parents may consider eye contact to be disrespectful. In the United States, eye-to-eye contact with the person with whom one is communicating is considered a show of respect and attention. In some Asian cultures, however, eye-to-eye contact is seen as disrespect

6. The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his younger sibling. What understanding would assist the nurse most in formulating a response? a. Preschool children can be disruptive in the hospital environment. b. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided. c. The sibling could view the infant from the doorway but not enter the room to prevent the spread of microorganisms. d. The preschooler needs to visit his infant sister to reassure himself that she is all right.

ANS: D Siblings are affected by a child's hospitalization. Their ability to cope is influenced by their age, experience, and intactness of the family.

12. The nurse notices that the mother of a child with cerebral palsy corrects and redoes many of the things the nurse does for her child. What is the nurse's most appropriate response to this mother? a. "Would you like to do all of your child's care?" b. "I'm doing the very best job that I can with your child." c. "Why don't you go have a cup of coffee? You are going to be exhausted if you don't take a break." d. "I'd love for you to share with me some of the special things you do for your child."

ANS: D The person who cares daily for the child with a chronic illness can provide information that will best guarantee continuity of care between the home and the hospital.

17. A 4-year-old begins to cry when his mother tells him it is time for his operation. The nurse understands this is an expected reaction. On which particular fear of the preschooler does the nurse base this understanding? a. Loss of control b. Restricted mobility c. Unfamiliar routines d. Invasive procedures

ANS: D The preschool-age child is afraid of bodily harm, particularly invasive procedures.

1. A parent comments that her infant has had several ear infections in the past few months. The nurse understands that infants are more susceptible to otitis media because: d. the eustachian tube is short, straight, and wide.

ANS: D An infant's eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear. DIF: Cognitive Level: Knowledge REF: p. 531 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

1. A parent comments that her infant has had several ear infections in the past few months. The nurse understands that infants are more susceptible to otitis media because: a. infants are in a supine or prone position most of the time. b. sucking on a nipple creates middle ear pressure. c. they have increased susceptibility to upper respiratory tract infections. d. the eustachian tube is short, straight, and wide.

ANS: D An infant's eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear. DIF: Cognitive Level: Knowledge REF: p. 531 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The nurse instructs the mother of a 2-year-old child who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse? d. Egg yolks

ANS: D Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement.

27. What would the nurse, who is preparing air travel instructions to prevent barotrauma in infants, include in teaching? Select all that apply. a. Using ear plugs during takeoff b. Holding infant upright during flight c. Omitting the meal just before takeoff d. Letting the infant nurse during descent e. Applying ear drops before takeoff

ANS: D Encouraging an infant to swallow reduces the pressure in the ears during descent.

11. The nurse explains that febrile seizures: a. occur when the body temperature exceeds 38.3 C (101 F). b. can be prevented by anticonvulsant medication. c. usually lead to the development of epilepsy. d. occur when the temperature rises quickly.

ANS: D Febrile seizures occur in response to a rapid rise in temperature, often above 38.8° C (102° F). DIF: Cognitive Level: Comprehension REF: p. 544 OBJ: 12 TOP: Febrile Seizures KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation

A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will assume for this procedure? d. "On your side with the knees bent and the head close to the knees."

ANS: D The child is positioned on his or her side with the knees flexed, and the head is brought down close to the flexed knees.

3. The situation in which the nurse would suspect a hearing impairment is a(n): d. 24-month-old toddler who communicates by pointing.

ANS: D The child who is not making verbal attempts by 18 months should undergo a complete physical examination. DIF: Cognitive Level: Analysis REF: p. 533 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The situation in which the nurse would suspect a hearing impairment is a(n): a. 3-month-old infant with a positive Moro reflex. b. 15-month-old toddler who is babbling. c. 18-month-old toddler who is speaking one-syllable words. d. 24-month-old toddler who communicates by pointing.

ANS: D The child who is not making verbal attempts by 18 months should undergo a complete physical examination. DIF: Cognitive Level: Analysis REF: p. 533 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Which strategy might the nurse use when administering oral medications to a young child who is reluctant? d. Offer the child fruit juice after the medication is swallowed.

ANS: D The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk because the child may develop distaste for it.

Where is the best site for giving an IM injection to a 15-month-old child? d. Vastus lateralis muscle

ANS: D The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? d. Position the child on the right side after a feeding.

ANS: D To prevent regurgitation and aspiration, the child is placed in the Fowler's position or on the right side to promote gastric emptying after a gastrostomy tube feeding.