Peds Quiz 1
A nurse is planning to administer immunizations to a 2-month-old infant. Which of the following is an appropriate action for the nurse plan to give? (Select all that apply.) a. Rotavirus (RV) b. Diphtheria, tetanus, and acellular pertussis (DTaP) c. Haemophilus influenzae type b (Hib) d. Hepatitis A (HepA) e. Pneumococcal conjugate (PVC13) f. Inactivated poliovirus (IPV)
A, B, C, E, F A: RV is given as a two-or three- close series starting at 2 months of age. B: DTaP is given as a five-dose series starting at 2 months of age. C: Hib is given as a three or four dose serious starting at 2 months of age. E: PCV13 is given as a four-dose series starting at 2 months of age. F: IPV is given as a four-dose series starting at 2 months of age.
A nurse is performing family assessment. Which of the following should the nurse include? (Select all that apply) a. Medical history b. Parent's educational level c. Child's physical growth d. Support system e. Stressors
A, B, D, E A: The nurse should include a medical history of the parents, siblings, and grandparents when performing a family assessment. B: The nurse should include the family structure, which includes family members, family size, roles/position within the family, and occupation and education of family members, when performing a family assessment. D: The nurse should include support systems to determine the availability of extended family, work and peer relationships, and social systems and community resources to assist the family in meeting needs when performing a family assessment. E: The nurse should include stressors, both expected and unexpected, when performing a family assessment.
A nurses is planning to administer recommended immunizations to a 4-year-old child. Which of the following vaccines should the nurse plane to give? (Select all that apply.) a. Inactivated poliovirus (IPV) b. Haemophilus influenzae type b (Hib) c. Measles, mumps, rubella (MMR) d. Varicella (VAR) e. Hepatitis B (HepB) f. Diphtheria, tetanus, and acellular pertussis (DTaP)
A, C, D, F A: Four does of IPV are given during childhood with a dose given at 4 years of age. C: Two doses of MMR are given during childhood with a dose given at 4 years of age. D: Two doses of VAR are given during childhood with a dose given at 4 years of age. F: Five doses of DTaP are given during childhood with a dose given at 4 years of age.
A nurse is performing a neurological assessment on an adolescent. Which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? (Select all that apply.) a. Clenching teeth together tightly b. Recognizing sour tastes on the back of the tongue c. Identifying smells through each nostril d. Detecting facial touches with eyes closed e. Looking down and in with the eyes
A, D A: Clenching teeth together tightly is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve. D: Detecting facial touches with eyes closed is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve.
Felipe's primary healthcare provider asks the nurse to keep as accurate a record as possible of Felipe's intake and output while he is undergoing diagnostic testing. Felipe vomits without warning on his gown and the floor. How should the nurse document this form of output to ensure an accurate assessment? a. Estimating the amount of emesis and describe the character in his health record b. Describing the event in Felipe's health record and note that it was not possible to gauge the quantity c. Weighing his soiled gown and compare the weight to a clean gown of the same size d. Asking his mother to approximate the amount that he vomited
A. Measuring the amount a child vomits (emesis) can be challenging if it spills onto clothing or bed linen. When this happens, the nurse should estimate the amount in relation to the amount of food or fluid the child recently ate and include the number of episodes and a description of the vomitus. The nurse should not delegate estimating the quantity of the vomitus to Felipe's mother.
CH 36 The nurse collaborates with an interprofessional team to care for Becky, age 7 years. The social worker believes that Becky is showing the first signs of separation anxiety. The nurse determines which symptoms of anxiety corroborate the social worker's assessment? a. Loud, demanding crying b. Silent, sullen protesting c. Quiet, introspective thought d. Inability to respond verbally
A. The nurse confirms that Becky's symptoms of anxiety may indicate separation anxiety. Protest, the first stage of separation anxiety, is marked by loud, intense crying.
John, who is 6 years old, says his broken leg wants to get better. When choosing an accurate and empathetic response, the nurse should be aware John is using what form of cognition? a. Magical thinking b. Deductive reasoning c. Concrete operational thinking d. Sensorial thought
A. The nurse recognizes that ascribing human properties to inanimate objects is indicative of magical thinking.
Felipe needs to have a 24-hour urine specimen collected and this will require the nurse to coordinate care with nurses on subsequent shifts. To ensure accurately timed collection, when would the nurse identify the collection's start point? a. The time you discard the first void b. The first time he voids in the morning c. A set time, which is most often 0700 d. At the time of his first void after the discarded urine
A. The nurse should start the 24-hour urine collections from the discard of the first urine to ensure it is truly a 24-hour specimen.
The nurse wants to teach Barry more about his hypercholesterolemia, and he has expressed a preference for video resources. To ensure that such videos are safe, age-appropriate, and accurate, the nurse should do which action? a. Preview any potential video resources before referring them to Barry. b. Encourage Barry to search YouTube and then report back to you. c. Emphasize the fact that written materials are usually preferable to video materials. d. Refer Barry to his local public library and have him liaise with a librarian.
A. Video resources must be vetted by the nurse to ensure that the material presented is evidence-based, safe, and age-appropriate.
In developing a plan for perioperative teaching for an adolescent, which is important for the nurse to recognize? a. Adolescents may act as if they know more than they actually do. b. An adolescent will not be interested in reassurance that things will go well. c. Postoperative teaching should wait until the surgery. d. The adolescent will need few explanations of the procedure because he or she has seen medical shows on television.
A: Adolescents may manifest an air of knowing more than they actually do as part of working through a sense of identity.
A nurse is caring for a toddler in a clinic. Which of the following actions should the nurse take? (See the chart for additional client information.) Demographics 15 months old Female Immunization record Hep B: 1 month, 2 months, 4 months, 6 months DTaP: 2 months, 4 months, 6 months Hib: 2 months, 4 months, 6 months IPV: 2 months, 4 months, 6 months MMR: 12 months Varicella: 12 months Hep A: 12 months Nurse notes Temperature: 37.8 C (100.1 F) Sore throat Family history of seizures a. Administer DTaP vaccine. b. Administer rotavirus vaccine. c. Hold immunizations until fever subsides. d. Administer hepatitis A vaccine.
A: Five diphtheria, tetanus, and acellular pertussis immunizations are given during childhood, with one at 15 months of age.
CH 35 PPT A 10-year-old girl is newly diagnosed with diabetes. The nurse plans to teach her about nutrition related to her diagnosis. Which is the best approach to teach this child? a. Play a diabetic nutrition trivia game with her. b. Show a video about meal planning. c. Giver her a list of foods she cannot have. d. Have the doctor teach her this information.
A: Learning through play is a valuable tool at this age. She may be bored by a video. Giving her a list of what she cannot have is a negative approach. This teaching is within the scope of the nurse.
CH 2 ATI A nurse is preparing to assess a preschool-age child. Which of the following is an appropriate action by the nurse to prepare the child? a. Allow the child to role-play using miniature equipment. b. Use medical terminology to describe what will happen. c. Separate the child from her parent during examination. d. Keep the medical equipment visible to the child.
A: The nurse should allow the child to role-play or manipulate equipment to reduce anxiety and fear related to the examination.
A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, "My son knows he better do what I say." Which of the following parenting styles is the parent exhibiting? a. Authoritarian b. Permissive c. Authoritative d. Passive
A: The parent is exhibiting an authoritarian parenting style. The parent controls the adolescent's behaviors and attitudes through unquestioned rules and expectations.
CH 34 PPT Which physical finding would best suggest that an infant is dehydrated? a. A depressed fontanelle b. A caput succedaneum c. Curved finger beds d. Listless appearance
A: With dehydration, the fontanelles of infants often appear sunken.
A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (Select all that apply.) a. Believes the experience is a punishment b. Experiences separation anxiety c. Displays intense emotions d. Manifests disturbance in body image
B, C, D B: Separation anxiety is a potential effect of hospitalization in a toddler C: Intense emotions are a potential effect of hospitalization in a toddler D: Behavior regression is a potential effect of hospitalization in a toddler.
Keoto's sister is 2 years old and appears fearful of medical equipment. To preserve her comfort, the nurse can exclude blood pressure measurement from assessment until what age? a. 2.5 years b. 3 years c. 5 years d. 7 years
B. Blood pressure is routinely assessed beginning at 3 years of age; therefore, the nurse can exclude this assessment in this case.
With the participation of her father, the nurse obtains a health history from Keoto. What question should the nurse ask at the end of this and every interview? a. "Where do you think we should go from here?" b. "Is there anything else you'd like to discuss?" c. "Are you still feeling okay?" d. "Am I a good interviewer? I'm trying hard."
B. Parents may be unwilling to discuss a chief concern until they feel comfortable with an interviewer. The nurse should provide an open-ended invitation to address any outstanding issues that can sometimes reveal important data.
The nurse wants to encourage Becky to drink a lot of water to promote hydration. During the most recent rounds, Becky drank an entire 10-oz glass at once and vomited several minutes later. Considering the failed attempt to encourage oral hydration, what would be the nurse's best next course of action? a. Teach Becky about the consequences of failing to drink sufficient water. b. Set up a plan with Becky and her parents to provide small glasses of water frequently. c. Continue to offer her large glasses of water so she does not have to drink so often. d. Alert her that if she does not increase her fluid intake she will likely have to receive IV fluids.
B. School children do best with small tasks and a feeling of reward. The nurse should use a collaborative approach with the caregivers to encourage Becky to drink more water in small glasses, which is also more likely to prevent nausea and vomiting. Warning her of negative consequences is less likely to result in positive outcomes.
Becky's mother and father ask the nurse what type of therapeutic play would be best for Becky. Which type of therapeutic play would best meet Becky's needs if she will have a large bandage on her foot after surgery? a. Letting her hold and handle a syringe (with no needle attached) b. Giving her a doll and a bandage to change c. Supplying a video tape of a child having surgery for her to watch d. Giving her a book to read about a child's hospitalization experience
B. The nurse could have Becky handle a bandage to address specifically what is happening to Becky. She can apply it to the foot and become more comfortable with the concept of a bandage. Therapeutic play materials are best if they are most relevant to a child's condition or procedures
Felipe will be having a fingertip puncture for serum glucose. The nurse determines which instruction is best to empower him before the procedure. a. "It won't hurt a bit; it's only a small finger prick." b. "Why don't you choose which finger you'd like me to use." c. "Most other boys your age don't mind this at all." d. "Make sure you hold still, otherwise you won't get a special treat."
B. The nurse giving Felipe a choice of fingers to use can interest him in the procedure. Comparing him to other children his age or threatening the withholding of privileges or treats is inappropriate nursing responses.
The nurse wants Barry, age 16 years, to increase his cognitive understanding of his condition. After teaching sessions, which statement from him would best show that his cognitive knowledge has increased? a. "I feel so much better now about the care I need." b. "I understand I have to take two types of medicine." c. "I've finally learned how to swallow big capsules." d. "I hate having to take medicine but will take it."
B. The nurse is teaching using cognitive learning, which is learning facts or increasing knowledge. A and D are affective learning; C is psychomotor or skill learning.
Pressing a tongue blade against the back of the throat causes a gag reflex. When would the nurse want the team members to know it is important not to elicit a gag reflex? a. When a child is under 5 years of age b. When a child has symptoms of epiglottitis c. When a boy has a possible inguinal hernia d. When a girl has a geographic tongue
B. The nurse should be aware that gagging a child who has a swollen epiglottis can cause the epiglottis to obstruct breathing.
CH 28 John is 6 years old. The nurse should teach his parents that which of his body systems should be reaching its peak point of development at this time? a. His neurologic system b. His lymphatic system c. His respiratory system d. His musculoskeletal system
B. The nurse should explain that the lymphatic system reaches such a peak in early school-age children; their throats appear to be "all tonsils."
Preventing obesity is a major healthcare goal worldwide. To determine if preschoolers are aware of what an average weight child looks like in contrast to one who is overweight, nurse researchers recruited 17 children between 4 and 5 years of age from preschool settings. Each child was weighed and measured for height so their body mass index (BMI) could be calculated and then shown images of children of various body shapes and sizes. All the children were able to correctly identify the body shape that depicted an overweight child as if they understood the concept of overweight. When asked if they liked their own body shape, however, even those who were overweight answered "yes" or apparently had difficulty applying the concept of overweight to themselves (Burgess & Broome, 2012). John shares a similar body shape with his mother and is overweight. The nurse identifies which statement by John as typical according to the study? a. "No one looks fat in my family." b. "I like the way I look in my uniform." c. "We look like the people in these pictures." d. "People shouldn't worry about what they look like."
B. Young children in the study recognized what overweight was but were unable to apply the concept to themselves. The nurse recognizes John's inability to connect his own appearance with the pictures is consistent with this tendency.
CH 36 PPT What would be a game. You might play to urge a school-aged child to ingest a high fluid intake? a. Hangman b. "Simon says" c. Battleship d. Hide and go seek
B: "Simon says" is a game that appeals to a school-aged child's developmental needs because it is concerned with rules."
CH 28 PPT A father brings his 18-month-old son to the clinic. He asks the nurse why his son is so difficult to please, has temper tantrums, and annoys him by throwing food from the table. Which principle of growth should the nurse explain? a. Toddlers need to be disciplined at this stage to prevent development of antisocial behaviors. b. The child is learning how to assert independence, and his behavior is considered normal for his age. c. This is abnormal behavior, and the father should be referred for psychological help. d. It is best to leave the child alone in the crib after calmly telling him why his behavior is unacceptable.
B: At 18 months of age, the child is learning to become independent and express his feelings. He does not have full command of his words and may use actions to express his feelings, such as throwing items.
CH 37 PPT Which is the best option for measuring a pulse on an infant? a. Radial pulse for 1 full minute b. Apical pulse for 1 full minute c. Anterior fontanelle for 1 full minute d. Brachial pulse for 1 full minute
B: Infants' heart rate may increase and decrease relative to their breathing patterns. Counting for less than 1 full minute may yield inaccurate results. In addition, peripheral
CH 10 ATI A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool age child? a. Describing manifestations of illness b. Relating fears to magical thinking c. Understanding cause of illness d. Awareness of body functioning
B: Preschool age children are egocentric and relate fears to magical thinking.
When assessing a child's heart, which of the following would be considered abnormal? a. Physiological splitting with inspiration b. Presence of a fourth heart sound c. An observable PMI d. Dullness with percussion
B: Presence of a fourth heart sound.
School-age children run a high incidence of pediculi. Of the following, which best suggests pediculi? a. Dry, brittle hair b. Small white particles on the hair strands c. Patches of hair loss d. Weeping circular areas of the scalp
B: The eggs of lice are revealed as small white particles on hair strands.
A nurse is assessing a 6-month-old infant. Which of the following reflexes should the infant exhibit? a. Moro b. Plantar grasp c. Stepping d. Tonic neck
B: The plantar grasp is exhibited by infants from birth to the age of 8 months.
Preschool children tend to "center" on information. Which is the best description of this action? a. They learn only the middle part of a procedure. b. They may concentrate on one part of a procedure and appear not to hear another. c. They have to have printed material directly in front of them to understand it. d. They do not retain information longer than a week.
B: To center means to concentrate on only one characteristic of an object or event (seeing a banana is yellow but not long).
Preparing children, through the use of parental preparation, for surgery can vary in effectiveness depending on the method of education. A study was conducted to determine if a preoperative DVD instructional program could have an effect on parental knowledge, participation, and anxiety and thereby reduce the distress, pain, analgesic requirements, and length of recovery in a child undergoing same day surgery. The DVD intervention was provided to 123 parent-children (ages 3 to 10 years) dyads undergoing same-day surgery, whereas the control group received standard care. Parents in the intervention group demonstrated an increase in knowledge, provided more positive reinforcement, and increased their use of distraction and relaxation methods toward their child as compared with the control group. The children's postoperative pain was significantly lower in the intervention group as compared with the intervention group (Chartrand, Tourigny, & MacCormick, 2017). Based on the previous study, what does the nurse determine for Wolf, 3 years old, if he seemed exceptionally anxious before surgery? a. Face-to-face instruction is preferable because it is most effective. b. He has no reason to feel anxious because 1-day surgery is finished so quickly. c. He should be given the choice between a Web-based/DVD program or face-to-face instruction. d. He, like most preschoolers, is too young to understand an explanation of his surgery.
C. Neither the Web-based/DVD program nor the face-to-face instruction was demonstrably superior; therefore, the nurse could allow the child to choose which delivery method he or she preferred.
One of the biggest problems with trying to reduce pain from a procedure such as a venipuncture or an injection is that anesthetic creams do not take effect until 30 minutes to an hour. To test whether commercial devices called a J-tip (a needle-free device for subcutaneous delivery of lidocaine) and the Buzzy (a cooled, vibrating device that uses gate control to minimize procedural pain) could serve as an effective distraction technique to immediately reduce pain, researchers prospectively investigated patients aged 1 month to 21 years. Participants were enrolled in phase 1 (J-tip only) and then phase 2 (Buzzy and J-tip) for analgesia prior to venipuncture or IV start. Results revealed that patients who received either intervention reported lower scores on pain scales during venipuncture or IV start than the group receiving no analgesia (Kearl, Yanger, Montero, et al., 2015). Based on this study, the next time Felipe needs to have blood drawn, the nurse's best action would be which of the following? a. Assessing Felipe's pain and anxiety levels before and after venipuncture b. Explaining that venipuncture feels much the same as a mild bee sting c. Planning a distraction technique for him that his mother thinks would be effective d. Explaining to Felipe that an attempt will be made to distract him before performing the procedure
C. The commercial device reduced pain by serving as a distraction. The nurse should collaborate with the mother to select a distraction technique that would be effective with Felipe because his mother may know what will work most best. Pre- and postprocedure assessment will not necessarily reduce his anxiety and pain. The nurse telling him that he or she will try to distract him may be counterproductive.
John, at 6 years old, is a school-age child. What should members of the nurse's interprofessional team recognize when caring for school-age children according to Freud? a. It's important for parents to teach children creativity during this time. b. Children develop their moral compass or spirituality during school-age years. c. Freud saw the school-age period as a largely latent or inactive period. d. Every school-age child needs responsibilities in order to learn trust and integrity.
C. The interprofessional team should recognize that Freud stressed that school age is a latent stage and that it is not a stage of great advancement.
The nurse has heard from a colleague that Barry, 16 years old, hates school. When considering the use of informatics to respond to this statement, which principle should guide the nurse's actions? a. Communication is most effective when it is enhanced by cutting-edge technology. b. Referral to an appropriate, evidence-based website can likely resolve this issue. c. Technology cannot usually substitute for skilled interpersonal communication. d. Communication skills are being replaced by technologic innovation in nursing.
C. The nurse should be guided by the principle that technology has the potential to enhance learning and communication, but it cannot wholly substitute for the nurse's sophisticated and thoughtful interpersonal communication skills.
CH 37 The nurse restrains Felipe to obtain a blood sample from his hand. The nurse determines which method of restraint is best? a. Asking his mother to hold him tightly on her lap b. Applying a jacket restraint to confine his body c. Asking a fellow nurse to hold his hand firmly d. Using a mummy restraint so he can't be hurt
C. The nurse should provide support during procedures using the least amount of restraint possible. In this case, the help of another nurse to hold the hand steady is the best choice. The mother may not be capable of restraining the child during the procedure in a safe manner.
CH 34 Over 300 children (from birth through age 19 years) in the United States are seen in the emergency room due to ingestion of poisonous substances. Substances include common household products and medications. It is important to provide guidance and injury prevention information to parents to prevent unintentional ingestions by children (CDC, 2016c). Based on this information, which would be the most important question to ask Candy's father? a. "Has Candy tried to drink something that you're drinking?" b. "Do you keep all your prescription drugs securely locked?" c. "What do you keep in the cupboards below your sinks?" d. "Where do you store the alcoholic beverages in your house?"
C. The nurse should teach the father that household products were swallowed most commonly by young children. These are often stored below sinks in bathrooms or kitchens. The nurse should question if these cabinets are locked if they contain household products.
John is a school-age child, but he still has difficulty learning Piaget's concept of conservation. The nurse recognizes this implies which statement about John? a. He doesn't understand why his mother insists he recycle plastic or metal soda cans. b. He doesn't understand that, when crossing a two-way street, he must look both right and left. c. He feels angry because his sister's piece of pie is long and thin where his is short and fat. d. He has an imaginary friend.
C. The nurse understands that conservation is learning that two different shapes can actually be equal in mass or volume, and John has not yet learned this concept.
The nurse wants Wolf, 3 years of age, to know how to do the hand exercises he will need to do after surgery. When collaborating with the physiotherapist, which technique below would probably be most effective with Wolf? a. A pamphlet you read together b. A lecture from a sports hero c. Playing a game of Simon Says d. A group discussion on hand pain
C. When teaching a 3-year-old, the nurse would probably do best by playing a game. Lecture, group discussion, and reading a pamphlet are all more advanced than this child's age level.
A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider? a. Temperature of 37.2 C (99.0 F) b. Heart rate 106/min c. Respirations 30/min d. Blood pressure 88/54 mm Hg
C: Respirations of 30/min is above the expected reference range for a 3-year-old child and should be reported to the provider
Which is the best way for an infant's father to help the child complete the developmental task of the first year? a. Expose her to many caregivers to help her learn variability. b. Talk to her at a special time each day. c. Respond to her consistently. d. Keep her stimulated with many toys.
C: The infant is in need of development of trust. Responding to the infant on a consistent basis develops the trust needed to meet the developmental task of infancy.
A nurse is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contraindication to administer the vaccine? a. "Do you have an allergy to eggs?" b. "Have you ever had encephalopathy following immunizations?" c. "Are you currently taking corticosteroid medication?" d. "Have you ever had an anaphylactic reaction to yeast?"
C: Varicella vaccine is contraindicated with patients who have been taking corticosteroids or other medications that affect the immune system for 2 weeks or longer.
CH 35 ATI A nurse is preparing to administer immunizations to a 4-month-old infant. Which of the following is an appropriate action for the nurse to take in providing traumatic care? a. Administer 81 mg of aspirin. b. Use the Z-track-method when injecting. c. Ask the parents to leave the room during the injection. d. Provide sucrose solution on the pacifier.
C: allowing an infant to suck on a pacifier with sucrose solution can decrease pain with immunizations and is an appropriate action for the nurse to take in providing atraumatic care.
Becky's mother is worried Becky will have a traumatic hospital experience. Which of the following would the nurse advise her to do to help make Becky's hospitalization less traumatic? a. Suggest she keep her visits short so Becky can spend time with her nurse. b. After visiting, don't tell Becky she is leaving. Just try to slip quietly away. c. Insist Becky have blood drawn by her bed because she fears the treatment room. d. Take Becky to the playroom, a place where she can feel free from being hurt.
D. A children's hospital playroom is designated as a "pain-free" zone to help the child cope with the stressors of hospitalization. Reducing the ill effects of separation and hospitalization to the extent possible should be a high priority for the nurse. The nurse should encourage parents to stay whenever possible and tell the child if they need to be separated from them for a time. The nurse should ensure all procedures are performed in the treatment room, not at bedside, so the child feels comfortable in the hospital room.
Felipe's mother is relieved that he does not need an MRI because she tells the nurse she "would not have not allowed that." What would be the nurse's best response to her? a. "MRIs are almost never used for children under 4 years so you don't have to worry." b. "Aren't you prepared to take some risks to ensure Felipe's well-being?" c. "If, at any point, Felipe does need an MRI, be prepared to change your mind." d. "What is the reason you wouldn't have allowed an MRI for your son?"
D. Most parents are anxious to have diagnostic tests done so their child's illness can be identified. The nurse should ask her why she feels the way she does, which might reveal that she needs a better understanding of what an MRI involves.
Preparing children and their families for surgery is crucial and also challenging. Prior to elective surgery, children and their families are often invited to visit the hospital, whereby the child is allowed to learn about the procedure in age-appropriate terms and express his or her concerns through play. Studies have investigated the use of providing age-appropriate preparatory information about procedures, through board games (Fernandes, Arriaga, & Esteves, 2014), interactive puppet shows (Cuzzocrea, Gugliandolo, Larcan, et al., 2013), or web-based programs. Utilizing different platforms not only informs and prepares the child but also reduces anxiety for the child and their caregiver(s). Based on the study, what would be the best outcome to establish after teaching Becky and her family about surgical process and her anticipated course of recovery? a. Becky and her family will adhere to preoperative and postoperative instructions. b. Becky will be able to describe the reasons why a surgical intervention is necessary. c. Becky will state that she understands the basic principles of asepsis better than before the teaching. d. Becky will state that she feels less anxious about the prospect of having her foot debrided.
D. The most significant outcome of teaching patients and their families about the perioperative process was a reduction in their anxiety. As an outcome of education, this is more important than being able to adhere to instructions, describe asepsis, or explain the rationale for surgery. While providing teaching, the nurse should also focus on reducing anxiety for the child and caregivers.
The nurse is using a stethoscope to auscultate the sound of Keoto's mitral heart valve closing. When determining where to listen, the nurse identifies which location as best? a. Over the anterior sternum b. The right 9th or 10th intercostal space c. The left interior rim of the left clavicle d. The fourth or fifth left intercostal space at the nipple line
D. The nurse identifies the fourth or fifth left intercostal space at the nipple line as the best place to assess mitral heart valve closing, although this is not its anatomical position.
The nurse is worried Becky's 2-year-old roommate might aspirate a toy the family friend brought in for her. Which of the following items is most likely to be aspirated and therefore poses the greatest risk to safety? a. Puzzle pieces b. Clothing for a baby doll c. Crayons d. Blocks that are 1-in. square
D. The nurse is aware that blocks that are 1-in. square are the smallest items that can fit in a toddler's mouth easily. The nurse should teach the parents that any item smaller than the internal roll on toilet paper is a dangerous size to be aspirated. The other listed toys do not pose a serious risk of aspiration.
John, who is 6 years old, is a school-age child. According to Erikson, the nurse should identify which developmental task to integrate health promotion activities with during this period? a. How to be creative b. How to think abstractly c. How to trust others d. How to do things well
D. The nurse should choose health promotions activities for John based on Erikson's theory that the developmental task of the school-age child is to learn industry or to do things well.
CH 35 The nurse wants to review some health educational materials with Barry, age 16 years. To maximize his learning and his comfort level, this activity should take place in which type of physical space? a. Intimate space b. Social space c. Public space d. Personal space
D. The nurse should perform teaching in personal space, which is a distance of about 18 in. to 4 ft, or conversational space. It is most appropriate for face-to-face teaching.
Keoto's father wants to be sure Keoto's immunizations are up to date. The nurse determines the immunization for HPV is recommended by which age? a. At 12 to 18 months of age b. Before kindergarten entrance c. At 16 years of age d. At 11 to 12 years of age
D. The nurse teaches the father that human papillomavirus virus (HPV) vaccine is typically administered at 11 to 12 years of age.
When preparing to perform routine physical assessments on several children, for which of the following children would the nurse expect to obtain blood pressure? a. A 6-month-old infant b. A 13-month-old infant c. A 2.5-year-old toddler d. A 3.5-year-old preschooler
D: Blood pressure is obtained older than 3 years of age.
A hospitalized 4-year-old cries and tries to bite during each physical assessment. Which statement by the parent would help the nurse? a. "Can you just come back later?" b. "He is just scared and can't help it." c. "I can't get him to stop biting at home, so I know I won't be able to do so here." d. "You are going to the 'timeout' chair if you try to bite again."
D: Limit setting is necessary with unacceptable behavior even though the child is hospitalized. Provision of behavioral guidelines helps the child to know what to expect
A nurse is teaching a parent about parallel play in children. Which of the following statements should the nurse include in the teaching? a. "Children sit and observe others playing." b. "Children exhibit organized play when in a group." c. "The child plays alone." d. "The child plays independently when in a group."
D: Parallel play is when the toddler plays independently but is among other children in a group.
A nurse is teaching a group of parents about separation anxiety. Which of the following information should the nurse include in the teaching? a. It is often observed in the school-age child. b. Detachment in the stage exhibited in the hospital. c. It results in prolonged issues of adaptability. d. Kicking a stranger is an example.
D: Physical aggression toward strangers is a behavior seen in the protest stage of separation anxiety.
CH 1 ATI A nurse manager on a pediatric floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing the developmental theory? a. Describes that stress is inevitable b. Emphasizes that change with one member affects the entire family c. Provides guidance to assist families adapting to stress d. Defines consistencies in how families change
D: The nurse should include that the developmental theory defines consistencies in how families change.
A nurse is assessing a child's ears. Which of the following is an expected finding? a. Light reflex is located at the 2 o'clock position. b. Tympanic membrane is red in color. c. Bony landmarks are not visible. d. Cerumen is present bilaterally.
D: The presence of cerumen bilaterally is an expected finding.
