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Child Health Nursing Partnering with Children & Families 3rd Edition by Jane W. Ball – Test Bank

 

Ball, Child Health Nursing, 3/E
Chapter 3

Question 1

Type: MCMA

A nurse is working with a pediatric client who is overweight. Which diseases are associated with pediatric obesity?

Standard Text: Select all that apply.

  1. Cardiovascular disease
  2. Asthma
  3. Infant mortality
  4. Diabetes

Correct Answer: 1,4

Rationale 1: Conditions such as cardiovascular disease have higher morbidity rates in certain cultural groups due to the high rate of obesity among the children of these groups.

Rationale 2: Asthma is not targeted as one of the disease having roots in pediatric obesity.

Rationale 3: Infant mortality is not significantly correlated to obesity.

Rationale 4: Conditions such as diabetes have higher morbidity rates in certain cultural groups due to the high rate of obesity among the children of these groups.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-1

 

Question 2

Type: MCSA

A Southern, nominally Pentecostal, African American pediatric client is being assessed during admission. He has braided, black, kinky hair, and he celebrates Kwanzaa. The nurse should document his ethnicity and race on the nursing admission form as:

  1. Ethnicity African American, race Black
  2. Ethnicity Black, race African American
  3. Ethnicity Pentecostal, race African American
  4. Ethnicity Southern, race Black

Correct Answer: 1

Rationale 1: His ethnicity is African American and his race is Black because race refers to biological similarities.

Rationale 2: His ethnicity is African American because ethnicity refers to the distinctive characteristics of one’s cultural background. His race is Black.

Rationale 3: His religion is Pentecostal, which would not be documented as religion is not part of ethnicity or race. His race is Black.

Rationale 4: His regional affiliation is Southern and his race is Black.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-1

 

Question 3

Type: MCSA

The nurse is working with a child newly enrolled in an English as a Second Language class. The nurse wants to teach the child about the importance of hand washing before meals and to not eat food dropped on the exam room floor. The best way to evaluate the child’s understanding of hygienic nutrition is to:

  1. Have the child repeat his interpretation of the information that was taught.
  2. Schedule a medical interpreter to accompany the patient to his next visit.
  3. Provide written materials in English about hygiene and diet for the client to take home.
  4. Have the nurse model proper hand washing before examining the child, and throw out the dropped cookie.

Correct Answer: 1

Rationale 1: When an interpreter is not available, asking the client to repeat his understanding of what was taught reveals how he understood the concepts discussed.

Rationale 2: In working with families with limited English proficiency, it is optimal to have a medical interpreter present for the entire visit. When teaching has been done, the nurse has a responsibility to assess client understanding; thus, an interpreter at the next visit will not help the nurse or the client now.

Rationale 3: Written materials in English hold minimal value for clients with limited understanding.

Rationale 4: The purpose of modeled behavior could be misunderstood if it is not accompanied by an explanation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-1

 

Question 4

Type: MCSA

The nurse in a multicultural health clinic recognizes that many cultures use non-Western means in combination with Western health care prescriptions to treat illness. The nurse needs to recognize that the individuals most likely to combine curanderismo with Western health care prescriptions are:

  1. African Americans
  2. Native Americans
  3. Asian Americans
  4. Mexican Americans

Correct Answer: 4

Rationale 1: African Americans are most likely to combine roots of voodoo, seen in Black Muslims, with Western health care prescriptions.

Rationale 2: Native Americans are most likely to combine the work of a medicine man with Western health care prescriptions.

Rationale 3: Asian Americans are most likely to combine acupuncture with Western health care prescriptions.

Rationale 4: Mexican Americans are most likely to combine curanderismo with Western health care prescriptions.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-2

 

Question 5

Type: MCSA

Unhappy with the treatment progress for their child with cancer, the parents choose to add dietary supplements, including megavitamins, as complementary medicine to the treatment plan. What would be the priority nursing diagnosis for this child?

  1. Impaired gas exchange
  2. Risk for injury
  3. Altered family processes
  4. Altered parenting

Correct Answer: 2

Rationale 1: The use of complementary therapies does not indicate impaired gas exchange.

Rationale 2: Risk for injury is the priority nursing diagnosis when complementary therapies are used. The nurse must be concerned for the child’s safety with respect to side effects, risks, and other implications of complementary therapy used with traditional Western medical treatments.

Rationale 3: There is no indication this family has altered family processes. The use of complementary therapies does not mean their processes are unusual.

Rationale 4: There is no indication the parents are using inappropriate parenting styles.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3-4

 

Question 6

Type: MCSA

The charge nurse is reviewing the care plans written by the unit’s staff nurses. The charge nurse recognizes that the NANDA nursing diagnosis most likely to be construed as culturally biased and possibly offensive is:

  1. Interrupted family processes related to shift in family roles secondary to demands of illness.
  2. Fear related to separation from support system during hospitalization.
  3. Noncompliance related to impaired verbal communication secondary to recent immigration from a non-English-speaking area.
  4. Spiritual distress related to discrepancy between beliefs and prescribed treatment.

Correct Answer: 3

Rationale 1: When one family member becomes ill, roles of other family members may be modified to meet the family’s needs. This is not a cultural variation.

Rationale 2: Any individual separated from her support system may experience fear. This is not a cultural variation.

Rationale 3: Noncompliance carries a negative bias. The inability to communicate effectively due to language differences does not mean the patient and/or family are noncompliant.

Rationale 4: If cultural beliefs are not in agreement with the treatment plan, this could lead to spiritual distress. It does not illustrate bias.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3-5

 

Question 7

Type: MCSA

The nurse is beginning to obtain information about the present illness and medical history from the child’s family. The “zone” of space that the nurse should plan to use include the:

  1. Public zone.
  2. Personal zone.
  3. Intimate zone.
  4. Social zone.

Correct Answer: 2

Rationale 1: The public zone involves a distance greater than six feet away from individuals and is used during communications with larger groups.

Rationale 2: The personal zone, 18 inches to three feet, is used when talking to individuals during interviewing and history taking.

Rationale 3: The intimate zone of within 18 inches is used during physical assessment.

Rationale 4: The social zone, three to six feet from the body, can be used when calling individuals from a waiting room.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-5

 

Question 8

Type: MCSA

The nurse is working with a family who has recently immigrated to this country. The nurse has recently studied Purnell’s Model for Cultural Competence (2002) and wants to respond to the family in a culturally acceptable manner. The most appropriate assessment question(s) would be:

  1. “In what places have you lived?” and “What do you miss about your native land?”
  2. “When I discuss your child’s problem with you, how close to you should I stand?”
  3. “What is the school system like in your native land?”
  4. “What does eye contact indicate?” and “When do you want me to make eye contact?”

Correct Answer: 1

Rationale 1: Identification of information about the native land is the beginning component of Purnell’s Model for Cultural Competence.

Rationale 2: Proximity, distance, and eye contact are concepts addressed by Giger and Davidhizar.

Rationale 3: Leninger’s sunrise model addresses educational differences.

Rationale 4: Proximity, distance, and eye contact are concepts addressed by Giger and Davidhizar.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-6

 

Question 9

Type: MCSA

The nurse is reviewing the charts from a multicultural health clinic. The nurse needs to know that for three cultures, the listed first name is actually the family name, while the individual’s given name is placed last. The three cultures with this variation are:

  1. French, German, and Irish.
  2. Cambodian, Filipino, and Korean.
  3. Canadian, Egyptian, and Haitian.
  4. Brazilian, English, and Jewish.

Correct Answer: 2

Rationale 1: In France, Germany, and Ireland, the family name is listed second.

Rationale 2: The listed first name is in fact the family name in Cambodian, Filipino, and Korean cultures.

Rationale 3: In Canada, Egypt, and Haiti, the family name is listed second.

Rationale 4: In Brazil and England, and in Jewish culture, the family name is listed second.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-6

 

Question 10

Type: MCSA

The nurse is working in the respiratory clinic. In assessing children for cystic fibrosis, the nurse recognizes that children from which genetic and biologic racial background are more likely to have assessment findings characteristic of cystic fibrosis?

  1. Asian
  2. White
  3. Hispanic
  4. Black

Correct Answer: 2

Rationale 1: Asians and Native Americans are more likely to experience alcohol abuse due to metabolic mechanisms.

Rationale 2: White children of certain geographic origins are more likely to manifest diseases such as cystic fibrosis and celiac disease.

Rationale 3: Hispanics and blacks have higher rates of lactose intolerance than those of other racial backgrounds.

Rationale 4: Blacks are more likely to experience obesity and sickle-cell disease.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-7

 

Question 11

Type: MCSA

During the assessment, the nurse notices that a Black baby has a darker, slightly bluish-hued patch about 5 × 7 cm on the buttocks and lower back. What is the nurse’s next action?

  1. Ask the mother about the cause of the bruise.
  2. Call the Department of Social Services (DSS) to report this as a sign of abuse.
  3. Confer with the physician the possibility of a bleeding tendency.
  4. Chart the presence of a Mongolian spot.

Correct Answer: 4

Rationale 1: Asking the mother about the cause of the bruise reveals cultural ignorance.

Rationale 2: The nurse who calls the DSS to report this patch as a sign of abuse will reveal ignorance in culturally competent assessments and possibly provoke harassment of the family.

Rationale 3: In choosing to confer with the physician, the nurse will reveal ignorance in culturally competent assessments.

Rationale 4: The nurse will chart the presence of a Mongolian spot, as this may be observed in races with dark skin tones.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-7

 

Question 12

Type: MCSA

The oncology nurse is working with patients from many cultural backgrounds. When assessing pain, the nurse should recall that members of which cultural group are more likely to remain quiet when experiencing severe pain?

  1. Hispanic
  2. Asian
  3. Italian
  4. Jewish

Correct Answer: 2

Rationale 1: Individuals from Hispanic cultures are not less likely to express severe pain.

Rationale 2: Individuals from Asian cultures are more likely to remain quiet when experiencing pain.

Rationale 3: Individuals from Italian cultures are not less likely to express severe pain.

Rationale 4: Individuals from Jewish cultures are not less likely to express severe pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-7

 

Question 13

Type: MCSA

The nurse working in a multicultural clinic recognizes that when the purpose of teaching is to promote the health of individual children, this effort should be directed to the authority responsible for the health care decisions. In certain cultural groups, health care decisions typically are made by the father. Therefore, the nurse should direct teaching efforts to the fathers in which cultures?

  1. European American
  2. African American
  3. Native American
  4. Appalachian

Correct Answer: 4

Rationale 1: European American cultures are usually more egalitarian.

Rationale 2: These patterns are matriarchal in some African American cultures.

Rationale 3: Tribal elders might make the decisions in some Native American cultures.

Rationale 4: Family dominance patterns in some Appalachian cultures are more likely to be patriarchal.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-8

 

Question 14

Type: MCSA

The nurse is working with a child whose religious beliefs differ from those of the general population. The best nursing intervention to use to meet the specific spiritual needs of this child and family is to:

  1. Ask, “What do you think caused the child’s illness?”
  2. Show respect while allowing time and privacy for religious rituals.
  3. Identify health care practices forbidden by religious or spiritual beliefs.
  4. Ask, “How do the child and family’s religious and spiritual beliefs impact their practices for health and illness?”

Correct Answer: 2

Rationale 1: Asking about practices, possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

Rationale 2: Showing respect while allowing time and privacy for religious rituals is an intervention.

Rationale 3: Asking about practices, possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

Rationale 4: Asking about practices, possible causes, and identifying forbidden practices may be part of the spiritual assessment process.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-8

 

Question 15

Type: MCMA

Access to health care often is less accessible to many groups of children and parents. Which factors can contribute to reducing access to health care?

Standard Text: Select all that apply.

  1. Transportation problems
  2. Lack of community healthcare facilities
  3. Lack of health insurance among low-income families
  4. Overload of clients resulting in inability to be seen in a timely fashion
  5. Communication difficulties if the family is unable to speak or read English

Correct Answer: 1,3,5

Rationale 1: Individuals who do not have free or affordable access to transportation may be unable to seek medical care when needed.

Rationale 2: Healthcare facilities are available nationwide. Although urban areas will have a larger number of facilities in this country, healthcare facilities would be available within the county or region.

Rationale 3: Even with the wide availability of healthcare facilities, many of these facilities will not accept clients without insurance or the ability to pay.

Rationale 4: While many healthcare facilities have an overabundance of clients, new facilities are opening up regularly. Walk-in, urgent care facilities are available in more communities.

Rationale 5: Communication difficulties may be a barrier to health care.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-3

 

Question 16

Type: MCMA

A new nurse takes a job in a clinic that works with immigrants from many different cultures. The nurse recognizes that to be culturally sensitive, the nurse will need to:

Standard Text: Select all that apply.

  1. Determine means to indoctrinate the patients in the American culture.
  2. Gain knowledge about the cultural groups attending the clinic.
  3. Avoid the use of interpreters to reduce the impression of a bias.
  4. Honor the cultural variations of the patients at the clinic.
  5. Acquire information and educational media, such as pamphlets and teaching videos, that use languages spoken by the cultural groups attending the clinic.

Correct Answer: 2,4,5

Rationale 1: Providing information about differences in culture is acceptable practice, but it is not appropriate to indoctrinate patients to the nurse’s own culture.

Rationale 2: In order to be culturally sensitive, it is appropriate to learn as much as possible about the cultures that live within the area served by the clinic.

Rationale 3: Interpreters will improve communication and should be utilized if necessary.

Rationale 4: Accepting cultural variations is important in being culturally sensitive.

Rationale 5: Being able to provide information in the languages spoken by groups that attend the clinic will help reduce barriers to communication.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3-8

 

Question 17

Type: MCSA

A child has been admitted to the hospital for treatment of otitis media. When explaining to the mother that the child will be treated for an ear infection, the mother states: “Oh, it is important that my child receives hot foods to help my child.” Recognizing that this is a cultural preference and that ear infections are “cold conditions,” the nurse will include which of the following in the child’s diet?

  1. Cheese and eggs
  2. Chicken and fish
  3. Fresh fruits and vegetables
  4. Goat meat and raisins

Correct Answer: 1

Rationale 1: Cheese and eggs are considered “hot” foods in many cultures and are used to treat cold conditions.

Rationale 2: Chicken and fish are considered to be “cold” foods and treat “hot” conditions, such as diarrhea.

Rationale 3: Fresh fruits and vegetables are considered “cold” foods and treat “hot” conditions, such as constipation and fever.

Rationale 4: Goat meat and raisins are considered “cold” foods and treat “hot” conditions, such as kidney problems and sore throats.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-8

 

Question 18

Type: MCSA

After reading a magazine article on complementary medicine methods, a teenager diagnosed with cancer asks the nurse about the possibility of adding CAM to the medical treatment plan. The nurse would explain to the child that prior to deciding on a CAM method, the adolescent must discuss:

  1. The cost of the CAM with her parents.
  2. The availability of CAM leaders with the hospital social worker.
  3. The safety of the chosen CAM modality with her primary physician.
  4. Alternative CAM methods with the nurse.

Correct Answer: 3

Rationale 1: Although discussion about cost is important, this is not the best response.

Rationale 2: Some CAM modalities may require an instructor/leader, and others may not. This is not the best answer.

Rationale 3: The priority concern about CAM modalities must be safety and the reaction of the CAM with the current medical treatment

Rationale 4: In considering CAM modalities, the patient and family may have options. It is acceptable to discuss this with a nurse, but safety should always be the primary concern.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3-8

Ball, Child Health Nursing, 3/E
Chapter 11

Question 1

Type: MCSA

The nurse is explaining the primary purpose of performing health maintenance activities at each pediatric visit. The best explanation touches on:

  1. Planning appropriate disciplinary measures for control of behavior.
  2. Reviewing developmental milestones with the parents.
  3. Prevention of disease and injury.
  4. Teaching growth and development to the parents.

Correct Answer: 3

Rationale 1: While it is important for parents to understand the normal growth and development, developmental milestones, and age-appropriate discipline measures for children of all ages, these are not the primary purposes of performing health maintenance activities at each pediatric visit.

Rationale 2: While it is important for parents to understand the normal growth and development, developmental milestones, and age-appropriate discipline measures for children of all ages, these are not the primary purposes of performing health maintenance activities at each pediatric visit.

Rationale 3: The primary purpose of health maintenance activities is prevention of disease and injury for children of all ages.

Rationale 4: While it is important for parents to understand the normal growth and development, developmental milestones, and age-appropriate discipline measures for children of all ages, these are not the primary purposes of performing health maintenance activities at each pediatric visit.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-1

 

Question 2

Type: MCMA

Which of these developmental milestones should the nurse expect to find in children who are between two and three years old?

Standard Text: Select all that apply.

  1. Always feeds self
  2. Throws ball overhand
  3. Kicks a ball
  4. Goes up and down stairs
  5. Scribbles and draws on paper

Correct Answer: 3,4,5

Rationale 1: Children between the ages of three and four years old feed themselves.

Rationale 2: Children between the ages of four and five years can throw a ball overhead.

Rationale 3: Children between the ages of two and three years old can kick a ball.

Rationale 4: Children between the ages of two and three years old can go up and down stairs.

Rationale 5: Children between the ages of two and three years old can scribble and draw on paper.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1

 

Question 3

Type: MCSA

A nurse who is the manager of an ambulatory pediatric health care center is planning protocols for the routine health care visits of the children. Children within the catchment area of this care center have a high incidence of obesity. The most important assessment data in monitoring the two-year-old child with obesity is:

  1. Weight alone.
  2. The child’s percentile score of height and weight and weight on the growth chart.
  3. Changes in the child’s percentile on the growth chart from birth to the present.
  4. The child’s body mass index.

Correct Answer: 4

Rationale 1: Weight cannot be used alone; weight in comparison to height provides clearer information.

Rationale 2: This can be helpful information, but it compares this child’s height to the average child of this age and this child’s weight to the average to the average child. It does not look at this child’s height to weight comparison.

Rationale 3: Children’s percentile findings on the growth chart may change from one evaluation to the next as they alternate between growth spurts and periods of slower growth.

Rationale 4: The body mass index is a comparison of the child’s weight to height and is the best tool for evaluating obesity.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3

 

Question 4

Type: MCSA

A nurse is preparing to perform a physical assessment on a toddler. Which of these actions should the nurse take?

  1. Explain each part of the examination to the child before performing it.
  2. Ask the mother to tell the child not to be afraid.
  3. Perform the assessment from head to toe.
  4. Leave intrusive procedures, such as ear and eye examinations, until the end.

Correct Answer: 4

Rationale 1: Explaining each part before performing it will only make the child more fearful, as it will make the entire procedure last longer.

Rationale 2: This will do little to alleviate the child’s fears.

Rationale 3: The nurse should complete the assessment in whichever order does not upset the child, leaving the head and genital areas for last.

Rationale 4: Intrusive procedures, such as examination of the ears, throat, eye, and genital areas, should be done last to decrease the anxiety of the child during the initial phases of the examination, which include the heart and lungs.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3

 

Question 5

Type: MCMA

The nurse recommends to the mothers of toddlers and preschoolers that they limit television to two hours a day. The nurse also discusses promoting physical activities that are related to kinesthesia. Which activities would the nurse suggest?

Standard Text: Select all that apply.

  1. Walking on a balance beam
  2. Reading
  3. Playing a memory game
  4. Skipping
  5. Giving up a pacifier

Correct Answer: 1,4

Rationale 1: Kinesthesia is the sense of one’s body position and movement, and it develops during the preschool years. Activities related to kinesthesia include skipping, walking on a balance beam, and throwing and catching a ball.

Rationale 2: Reading is a cognitive activity.

Rationale 3: Playing a memory game is a cognitive activity.

Rationale 4: Kinesthesia is the sense of one’s body position and movement, and it develops during the preschool years. Activities related to kinesthesia include skipping, walking on a balance beam, and throwing and catching a ball.

Rationale 5: A pacifier is used to soothe and calm infants.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-3

 

Question 6

Type: MCSA

A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which would be the most appropriate action for the nurse to take?

  1. Instruct the father to hold the toddler down tightly to complete the examination.
  2. Allow the toddler to sit on the parent’s lap and begin the assessment.
  3. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler’s behavior.
  4. Allow the toddler to stand on the floor until the crying stops.

Correct Answer: 2

Rationale 1: The father should not be asked to restrain the child for the entire examination.

Rationale 2: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way.

Rationale 3: If a child needs to be subdued, then another nurse should be the one to assist. However, in this case the goal is to calm the child so that the assessment can be completed.

Rationale 4: Allowing the toddler to stand on the floor is not going to calm the child so that the assessment can be completed.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

 

Question 7

Type: MCSA

Parents of a preschool-age child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents?

  1. “Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child.”
  2. “Let’s talk about other forms of discipline that have a more positive effect on the child.”
  3. “I think you are not parenting your child properly, so let’s talk about ways to improve your parenting skills.”
  4. “Can you try only spanking the child every other day for one week and see how that affects the child’s behavior?”

Correct Answer: 2

Rationale 1: To suggest spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

Rationale 2: The behavior reported by the parent was excessive. The only response that is appropriate is to seek a more positive way of influencing the child’s behavior.

Rationale 3: This comment is inappropriate, and it will cause the parents to become defensive of their actions.

Rationale 4: Making the suggestion for parents to spank even every other day is inappropriate.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

 

Question 8

Type: MCSA

A parent questions how her toddler will interact with other toddlers. The nurse’s best description of the differences in play between the toddler and the preschooler is:

  1. Toddlers play “side by side,” while preschoolers play cooperatively.
  2. Toddlers play cooperatively, while preschoolers play interactive games.
  3. Toddlers play house and imitate adult roles, while preschoolers become the “mom or dad” while playing house.
  4. There are no differences between toddlers and preschoolers because both play cooperatively.

Correct Answer: 1

Rationale 1: Toddlers, although they will play “side by side” with another child, will not interact with the child during play.

Rationale 2: Preschoolers play cooperatively with other children. Toddlers do not play cooperatively.

Rationale 3: Toddlers do not play house or imitate the adult roles.

Rationale 4: Only preschoolers play cooperatively with other children.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

 

Question 9

Type: MCSA

At a routine health care visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data?

  1. The toddler is proportionate for age.
  2. The height and weight are disproportionate, and the toddler needs further evaluation.
  3. The toddler needs to eat more at each feeding.
  4. The family most likely is short.

Correct Answer: 2

Rationale 1: The height and weight for the child described in this question are a concern, and the child might need further endocrine testing.

Rationale 2: Usually, height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child’s height usually also is greater than the 50th percentile.

Rationale 3: The concern is that the weight is out of proportion to the height. Further evaluation is needed.

Rationale 4: The family might be short, but a difference this great between height and weight needs to be referred for further evaluation and testing.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-6

 

Question 10

Type: MCMA

The nurse is teaching a group of mothers of toddlers and preschoolers about oral care and the prevention of caries. Which statements should the nurse include in the presentation?

Standard Text: Select all that apply.

  1. “The tendency toward dental caries is inherited.”
  2. “Fruit juice is an excellent source of vitamin C, so allow your child to drink as much fruit juice a day as desired.”
  3. “If your child is under two, you should use toothpaste without fluoride.”
  4. “Three-year-old children are mature enough to be able to brush their teeth independently.”
  5. “The child should see a dentist by one year of age.”

Correct Answer: 3,5

Rationale 1: Poor oral care may be passed from parent to child, but dental caries are not inherited.

Rationale 2: Fruit juice is high in sugar and may promote cavities. The amount of juice per day should be limited.

Rationale 3: A young child may be unable to spit out the toothpaste and will swallow it. To avoid children ingesting too much fluoride, parents should use toothpaste without fluoride.

Rationale 4: The three-year-old child is not mature enough to brush independently. Although the child should be allowed to attempt to brush, the parent should ensure the teeth are adequately cleaned.

Rationale 5: Early attention to dental health improves the condition of the primary teeth.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-5

 

Question 11

Type: MCSA

The home health nurse is observing the home environment for safety issues to discuss with the mother. Which observation creates a risk of injury for the toddler?

  1. The mother fills the mop bucket and places it on the floor. She then leaves the room to obtain the mop.
  2. When cooking, the mother only uses the back burners of the stove.
  3. The mother straps her child into the high chair.
  4. The mother has child-proof latches only on the cabinets containing household chemicals, medications, and poisons.

Correct Answer: 1

Rationale 1: Children can drown in 6 inches of water or less. A curious toddler may fall into the bucket and not have the dexterity to get out and drown.

Rationale 2: This is a safe practice as toddlers can reach up and pull pans off the stove or reach up and touch a hot burner.

Rationale 3: Toddlers like to climb and can be very quick. By strapping the child into the chair, the mother is reducing the risk of a fall.

Rationale 4: This is a convenience issue for the mother. If the cabinet does not contain any danger to the child, the doors do not need to be child-proof.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-5

 

Question 12

Type: MCMA

The pediatric clinic is scheduled to be remodeled. The charge nurse has been asked to design the new well-child waiting area. In planning the area, the nurse will want to include:

Standard Text: Select all that apply.

  1. Subdued colors to help calm the children.
  2. A separate area where parents can sit and not be disturbed by the children’s noise.
  3. Avoiding carpet and draperies which cannot be readily cleaned.
  4. Coloring books, crayons, and story books that are stored on a low shelf for easy child access.
  5. All wall decorations securely fastened to the walls.

Correct Answer: 3,4,5

Rationale 1: Bright colors would be a better choice to interest and engage the children.

Rationale 2: Parents need to be in the same area to monitor their children’s activity and maintain a safe environment.

Rationale 3: All surfaces should be easily cleaned to remove micro-organisms.

Rationale 4: Activities to distract the waiting children should be readily available.

Rationale 5: This will prevent the child from pulling objects down on themselves.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-5

 

Question 13

Type: MCSA

During a well-child visit, the nurse questions the mother about a toddler’s food habits. The mother expresses concern that her child, who used to be a good eater and would eat all types of vegetables, now refuses all but three types of vegetables. Which is the appropriate response for the nurse to make to the mother?

  1. “This is a serious concern, and we need to address this with the physician.”
  2. “Toddlers often go on food jags. Just continue to offer all types of vegetables without making it an issue.”
  3. “Don’t make an issue over it. Just stop offering those favorite vegetables and the child will start eating other vegetables.”
  4. “Have you thought about adding a multivitamin to the child’s daily routine?”

Correct Answer: 2

Rationale 1: Food jags are common in this age group.

Rationale 2: Food jags come and go. Unless the avoidance becomes extreme, it does not present a major problem.

Rationale 3: A variety of vegetables should be offered including the favorite ones.

Rationale 4: While a multivitamin is often a good idea during the toddler period, this statement does not address the mother’s concern about the food jags.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

 

Question 14

Type: MCMA

The mother of an 18–month-old expresses concern that her toddler is having temper tantrums when things don’t go her way. What advice should the nurse offer the mother?

Standard Text: Select all that apply.

  1. “This is common in the toddler and represents a loss of self-control.”
  2. “Remove the child from the area where the tantrum occurs.”
  3. “Provide a distraction for the child without giving in to the child’s desire.”
  4. “Remain calm while handling the child and do not raise your voice to the child.”
  5. “If the tantrum continues for more than a few minutes, the mother should tap the child lightly on the behind to remind the child the consequences of misbehavior.”

Correct Answer: 1,2,3,4

Rationale 1: This statement is accurate and reassures the mother that the behavior is a common age variation.

Rationale 2: The goal is to allow the toddler to regain control without a loss of self-esteem. Removing the child from the area will help the child to regain control.

Rationale 3: This is another activity to help the child regain control without a loss of self-esteem. By not giving in to the child’s wishes, the child is not learning to use temper tantrums to get her way.

Rationale 4: This will provide a calming atmosphere that will help the child to regain control.

Rationale 5: It is not a good idea to recommend spanking to any parent. Spanking is counterproductive in helping the child regain control.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

 

Question 15

Type: MCSA

The mother of a toddler asks the nurse: “Now that my child has outgrown his infant car seat, what should I do when we are in the car?” Which is the best response by the nurse?

  1. “Place him in a booster chair on the seat beside you so you can watch him.”
  2. “Be sure to select a car seat according to his weight and height, and make sure it contains shoulder harnesses.”
  3. “Your child should remain in the rear-facing car seat until he reaches 40 pounds.”
  4. “The child can now be buckled safely into the regular car seat belts.”

Correct Answer: 2

Rationale 1: The safest place for the child is in the back seat.

Rationale 2: This is correct information.

Rationale 3: This is incorrect. The rear-facing car seats usually have a weight limit of 20 pounds, after which the child is turned forward.

Rationale 4: This is incorrect information. Young children are better protected in a child car seat with harness straps.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

Ball, Child Health Nursing, 3/E
Chapter 25

Question 1

Type: MCSA

A toddler has had recurrent respiratory infections. The mother of the child expresses concern that her infant seems to be at increased risk for complications from respiratory infections in comparison with her older children. The best response from the nurse would be:

  1. “You are incorrect in your assessment.”
  2. “The younger child’s airways are smaller and more easily occluded.”
  3. “Air passages are more likely to become blocked with mucus because younger children make more mucus than older children.”
  4. “Toddlers do not breathe as deeply as do older children.”

Correct Answer: 2

Rationale 1: The mother is correct in her statement.

Rationale 2: Airways are smaller in the younger child and are more easily occluded when mucus is produced.

Rationale 3: Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent.

Rationale 4: Depth of breathing is not age-dependent.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-1

 

Question 2

Type: MCSA

A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). The nurse should be prepared to perform which intervention?

  1. Administer antibiotics and assist with possible intubation.
  2. Obtain a sputum specimen.
  3. Swab the throat for a throat culture.
  4. Administer nebulized epinephrine and oral or IM dexamethasone.

Correct Answer: 4

Rationale 1: Antibiotic administration and possible intubation are associated with epiglottitis.

Rationale 2: Sputum specimens will not assist in the diagnosis of LTB.

Rationale 3: Throat cultures are not obtained for LTB, because it is viral, and swabbing the throat could cause complete obstruction to occur.

Rationale 4: Nebulized epinephrine and dexamethasone are given for LTB.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-3

 

Question 3

Type: MCSA

Which nursing diagnosis would be most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?

  1. Activity intolerance
  2. Tissue perfusion, ineffective (peripheral)
  3. Pain, acute
  4. Decreased cardiac output

Correct Answer: 1

Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply and demand.

Rationale 2: Tissue perfusion (peripheral) is not affected by this respiratory disease process.

Rationale 3: Pain is not usually associated with acute bronchiolitis.

Rationale 4: Cardiac output is not compromised during an acute phase of bronchiolitis.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25-5

 

Question 4

Type: MCSA

A child is admitted to the hospital with pneumonia. The child’s oximetry reading is 88% upon admission to the pediatric floor. The priority nursing activity for this child would be to:

  1. Begin administration of intravenous fluids.
  2. Obtain a blood sample to send to the lab for electrolyte analysis.
  3. Begin oxygen per nasal cannula at 1 liter.
  4. Medicate for pain.

Correct Answer: 3

Rationale 1: Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child’s oxygenation status has been addressed.

Rationale 2: Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child’s oxygenation status has been addressed.

Rationale 3: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula at 1 liter should be started initially.

Rationale 4: Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child’s oxygenation status has been addressed.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-3

 

Question 5

Type: MCSA

A two-year-old male child arrived in the emergency department with complaints of sore throat, difficulty swallowing, and suspected diagnosis of acute epiglottitis. Which of the following interventions should not be included in the child’s immediate care and assessment?

  1. Throat culture
  2. Medical history
  3. Vital signs
  4. Assessment of breath sounds

Correct Answer: 1

Rationale 1: Throat cultures should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and can cause complete occlusion of the airway.

Rationale 2: Medical history should be obtained, which assists in diagnosis.

Rationale 3: Vital signs should always be taken when assessment is done.

Rationale 4: Assessment of breath sounds is essential for diagnosis.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-6

 

Question 6

Type: MCSA

The family rushes a four-month-old infant to the hospital after finding the infant not breathing. The child is diagnosed as a victim of sudden infant death syndrome. Supportive care for this family would include:

  1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints.
  2. Allowing parents to hold, touch, and rock the dead infant.
  3. Advising parents that an autopsy is not necessary.
  4. Interviewing parents to determine the cause of the SIDS incident.

Correct Answer: 2

Rationale 1: Parents will want any personal items available.

Rationale 2: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby.

Rationale 3: The death of an infant without a known medical condition is an indication for an autopsy.

Rationale 4: The parents need to know that SIDS is not their fault.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-6

 

Question 7

Type: MCSA

The nurse is teaching a group of mothers of infants about the benefits of immunization. The nurse will explain that the life-threatening disease epiglottitis can be prevented by immunization against:

  1. Hepatitis B.
  2. Polio.
  3. Measles, mumps, and rubella (MMR).
  4. Haemophilus influenzae type B (HIB).

Correct Answer: 4

Rationale 1: Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 2: Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 3: Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 4: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-5

 

Question 8

Type: MCSA

A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the clinic and report that the child’s urine is orange. The nurse should advise the parents to:

  1. Encourage the child to drink cranberry juice.
  2. Expect orange-colored urine while the child is on rifampin.
  3. Bring the child to the clinic for a urinalysis.
  4. Bring the child to the clinic for a radiograph of the kidneys.

Correct Answer: 2

Rationale 1: Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

Rationale 2: Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect.

Rationale 3: Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

Rationale 4: Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-6

 

Question 9

Type: MCSA

The nurse is evaluating the parent’s understanding of teaching related to environmental control for their child’s asthma management. Which statement by the parents indicates that they understand the teaching?

  1. “We’re glad the dog can continue to sleep in our child’s room.”
  2. “We’ll keep the plants in our child’s room dusted.”
  3. “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
  4. “We will replace the carpet in our child’s bedroom with tile.”

Correct Answer: 4

Rationale 1: When possible, pets and plants should not be kept in the home.

Rationale 2: When possible, pets and plants should not be kept in the home.

Rationale 3: Smoke from fireplaces should be eliminated.

Rationale 4: Control of dust in the child’s bedroom is an important aspect of environmental control for asthma management.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 25-7

 

Question 10

Type: MCSA

A newborn who is 24 hours old is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse what symptoms made the physician suspect cystic fibrosis. The nurse would reply that the clinical manifestation of cystic fibrosis that is seen first is:

  1. Rectal prolapse.
  2. Constipation.
  3. Steatorrheic stools.
  4. Meconium ileus.

Correct Answer: 4

Rationale 1: Rectal prolapse is a complication of the large, bulky fatty stools.

Rationale 2: Constipation is not a symptom of cystic fibrosis.

Rationale 3: Steatorrhea and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child.

Rationale 4: Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-7

 

Question 11

Type: MCSA

The nurse is teaching the parents of a patient who is newly diagnosed with cystic fibrosis how to administer the pancreatic enzymes. The nurse will advise the parents to administer the enzymes:

  1. qid (four times daily).
  2. bid (twice daily).
  3. With meals and snacks.
  4. Every six hours around the clock.

Correct Answer: 3

Rationale 1: A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 2: A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 3: Pancreatic enzymes are administered with meals and large snacks.

Rationale 4: A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-7

 

Question 12

Type: MCSA

A mother of a three-year-old tells the nurse that her child often puts small toys in his mouth and she is concerned about choking. She asks the nurse what she should do if the child chokes. In addition to recommending the mother take a CPR course, the best response by the nurse would be to:

  1. Show the mother how to do cardiac compressions and rescue breathing.
  2. Recommend the mother perform back blows and chest thrusts.
  3. Teach the mother how to perform abdominal thrusts.
  4. Tell the mother to do nothing until the child loses consciousness.

Correct Answer: 3

Rationale 1: Cardiac compressions and rescue breathing is not the first thing that the mother needs to know.

Rationale 2: This is the treatment for a choking infant, not a child.

Rationale 3: Giving abdominal thrusts is the correct intervention for a choking child.

Rationale 4: The mother should respond to the choking child before the child loses consciousness.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-5

 

Question 13

Type: MCMA

A premature infant develops acute respiratory distress syndrome (ARDS). How will the nurse position the baby?

Standard Text: Select all that apply.

  1. Upright
  2. Semi-Fowler’s position
  3. Prone position
  4. With his head hyperextended
  5. With his head in a sniffing position

Correct Answer: 2,5

Rationale 1: An infant cannot be placed in an upright position.

Rationale 2: The semi-Fowler’s position elevates the head of bed. This allows better movement of the diaphragm.

Rationale 3: Prone positioning will not promote respirations.

Rationale 4: The head should not be hyperextended as that position does not open the airway in an infant.

Rationale 5: A sniffing position straightens and shortens the airway and is the position that is best.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-6

 

Question 14

Type: MCSA

Two hours after admission for asthma exacerbation, the 10-year-old boy is lethargic with mottled skin color. He has increased the use of accessory muscles and demonstrates nasal flaring. He is unable to speak and his respiratory rate has increased. The nurse would suspect:

  1. Improvement in his condition is imminent.
  2. Respiratory failure is imminent.
  3. The medical diagnosis is incorrect and the child should be diagnosed with pneumonia.
  4. The child may be receiving too much oxygen, which is a respiratory depressant.

Correct Answer: 2

Rationale 1: His condition has worsened.

Rationale 2: These are symptoms of impending failure. Intervention is necessary.

Rationale 3: Pneumonia is a complication of asthma exacerbation but that doesn’t indicate the medical diagnosis is incorrect.

Rationale 4: There is no indication the child is receiving too much oxygen.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-3

 

Question 15

Type: MCSA

After a routine vaginal delivery, the infant transitions with the mother in the recovery room without difficulty. Prior to being discharged from the recovery room, it is noted that the infant’s respiratory rate is 102 and the lungs are clear to auscultation. Based on these findings, an appropriate transfer for this infant would be to:

  1. The newborn nursery for the first bath.
  2. The NICU and placed under an over-bed warmer for observation.
  3. To the mother’s room to promote bonding with the parents.
  4. The newborn nursery for its first feeding.

Correct Answer: 2

Rationale 1: The infant is tachypneic. Bathing will only add to the respiratory distress and should be avoided.

Rationale 2: This infant needs to remain under constant observation due to the respiratory rate.

Rationale 3: The infant needs to be monitored.

Rationale 4: With a respiratory rate this high, aspiration is likely so feeding should be avoided.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-4

 

Question 16

Type: MCSA

A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event). The physician is to see the infant to write medical orders. The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently?

  1. Place the child on an apnea monitor.
  2. Place the child on nasal cannula oxygen.
  3. Draw blood for arterial blood gases.
  4. Place the child on contact isolation.

Correct Answer: 1

Rationale 1: This is appropriate monitoring of the infant.

Rationale 2: Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen.

Rationale 3: Lab tests are not an independent action.

Rationale 4: There is no indication of a respiratory infection. At this time, contact isolation is not indicated.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-4

 

Question 17

Type: MCSA

An infant was born at 34 weeks’ gestation and is being treated in the NICU for apnea of prematurity. The infant is in an isolette with an apnea monitor and intravenous fluids. The apnea monitor sounds, and the nurse checks the infant to find the infant is not breathing. The initial intervention by the nurse would be to:

  1. Administer oxygen.
  2. Perform back blows and chest thrusts.
  3. Call a code.
  4. Stroke the infant’s back.

Correct Answer: 4

Rationale 1: If the infant is not breathing, oxygen will not help.

Rationale 2: This is intervention for choking, not apnea.

Rationale 3: A code is not the initial response. If the nurse is unable to restart breathing, then a code should be initiated.

Rationale 4: Tactile stimulation is often sufficient to restart the infant’s respirations. Apnea of prematurity is due to immaturity of the respiratory center.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-2

 

Question 18

Type: MCMA

A child is being discharged from the hospital following treatment of asthma. Discharge medications include cromolyn sodium (a mast cell stabilizer). Nursing instructions to the parents about this medication would include explaining:

Standard Text: Select all that apply.

  1. The medication works to prevent exacerbations.
  2. The medication should be administered at the first symptom of an asthmatic attack.
  3. The medication should be taken on a daily basis.
  4. Avoid taking the medication if the child has symptoms of a cold.
  5. The medication desensitizes the child against specific allergens.

Correct Answer: 1,3

Rationale 1: This statement is true. Cromolyn Sodium is used to inhibit an asthmatic response to allergens.

Rationale 2: This is incorrect. This medication does not improve the child’s condition during an asthmatic attack.

Rationale 3: This is a preventative medication so doses should not be missed.

Rationale 4: The medication should be taken daily.

Rationale 5: This medication does not desensitize the child against allergens.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-7

 

Question 19

Type: MCSA

The nurse stops at the scene of an accident and finds a child conscious but with a sucking wound of the chest. The immediate action by the nurse would be to:

  1. Place the child in trendelenburg.
  2. Begin rescue breathing.
  3. Begin cardiac resuscitation.
  4. Cover the wound with an air occlusive dressing.

Correct Answer: 4

Rationale 1: This would not be the appropriate response to a sucking chest wound.

Rationale 2: The child is conscious. Rescue breathing is not appropriate at this time.

Rationale 3: There is no need for cardiac resuscitation at this time.

Rationale 4: This prevents more air from entering the chest and is appropriate.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-8