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Pediatric Nursing An Introductory Text 11th edition by Debra L. Price – Test Bank 

 

 

Price: Pediatric Nursing, 11th Edition

 

Chapter 03: Pediatric Procedures

 

Testbank

 

MULTIPLE CHOICE

 

  1. As part of the preparation for obtaining a throat swab from a toddler, the nurse will:
a. Bring all equipment to the bedside prior to explaining the procedure to the child
b. Tell the toddler several hours in advance
c. Have the parent restrain the child
d. Give a brief simple explanation to the child

 

 

ANS:   D

The toddler should receive a simple explanation just before the procedure. The equipment should not be brought to the bedside until explanations have been given to the child and the parent. The parents can hold the child but should not be seen as the restrainer.

 

DIF:    Cognitive Level: Application             REF:    p. 33                OBJ:    2

TOP:    Preparation for Procedures                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is aware that the most effective form of comfort for an 11-year-old school-age child after a painful procedure is:
a. Therapeutic holding by the parent
b. Praise for cooperation
c. A Mickey Mouse sticker
d. A lollipop

 

 

ANS:   B

The older school-age child responds well to praise. Therapeutic holding, candy, and colorful stickers are childish.

 

DIF:    Cognitive Level: Application             REF:    p. 33                OBJ:    2

TOP:    Preparation for Procedures                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. In demonstrating technique for bathing an infant, the home health nurse stresses to the parents considerations such as:
a. Always run hot water first to prevent chilling
b. Wrap the circumcised penis in waterproof plastic
c. Apply lotions, not powder, after the bath
d. Mild bubble bath will lubricate the skin

 

 

ANS:   C

Use lotions rather than powder due to the risk of aspiration. Cold water should be run in the tub first. Circumcised infants should be sponged until circumcision is healed. Bubble baths may cause vaginitis in infants.

 

DIF:    Cognitive Level: Application             REF:    pp. 34-35         OBJ:    3

TOP:    Bathing an Infant or Small Child       KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Health Promotion and Maintenance: Basic Care and Comfort

 

  1. Prior to obtaining a clean-catch specimen from a 4-year-old, the nurse could best get the child to comply by:
a. Telling the child to void in the cup
b. Using the term the child uses for urination in explanations
c. Gently washing the perineum, holding the cup in place, and asking the child to void
d. Catheterizing the child

 

 

ANS:   B

The child will not understand what a clean-catch urine specimen is, so the nurse should explain to the child what is needed. The nurse should discover what term the child uses for urination, because the other terms may also be meaningless. Catheterization is unnecessary.

 

DIF:    Cognitive Level: Application             REF:    pp. 36-37         OBJ:    4

TOP:    Collection of Specimens                    KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A child with spina bifida requires home catheterization. The child is now old enough to learn how to perform this procedure himself. The child is taught:
a. Clean the tip of the penis with soap and water or Betadine
b. Insert the catheter 3 inches
c. Do not lubricate the catheter if reusing
d. Never reuse the catheter

 

 

ANS:   A

The tip of the penis should be cleaned with soap and water or Betadine. The catheter should be inserted until urine is returned. Always lubricate the catheter before insertion. The catheter can be cleaned, dried, and reused for 1 week without increasing the risk of infection.

 

DIF:    Cognitive Level: Application             REF:    p. 39                OBJ:    4

TOP:    Specimen Collection                          KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. In order to lessen the discomfort of a venipuncture for a blood draw for a 3-year-old child, the nurse may apply EMLA (local anesthetic cream) to the antecubital fossa:
a. Immediately prior to venipuncture
b. 10 minutes prior to venipuncture
c. 30 minutes prior to venipuncture
d. 60 minutes prior to venipuncture

 

 

ANS:   D

EMLA cream should be applied 60 minutes prior to venipuncture. Children older than 2 years of age usually have blood drawn from the antecubital fossa.

 

DIF:    Cognitive Level: Application             REF:    p. 40                OBJ:    5

TOP:    Collection of Blood Specimens         KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. After a blood draw from the antecubital fossa of a 5-year-old child, the child continues to cry and to press his hand against the puncture site. The nurse’s best intervention would be to say:
a. “Big kids don’t cry. It is all over, and you are just fine. Let’s go to the playroom.”
b. “This big band aid will fix that hole, and you won’t have to hold it anymore. You were very brave!”
c. “Tell this stuffed bear how much that needle sticking in your arm hurt.”
d. “Let’s go get some ice to put on that hole in your arm.”

 

 

ANS:   B

Preschoolers may fear continuously losing blood from the puncture site. The placement of a large bandage reassures them that their body fluids will not leak out.

 

DIF:    Cognitive Level: Application             REF:    p. 40                OBJ:    5

TOP:    Collection of Blood                           KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse while assisting the physician with a lumbar puncture of a small child will take special precaution to closely monitor the:
a. Blood pressure
b. Pulse
c. Respiratory status
d. Temperature

 

 

ANS:   C

The nurse would monitor the respiratory status of the child during the procedure. Respiratory obstruction is a risk when the neck is flexed. The other vital signs would be monitored before the beginning of the procedure.

 

DIF:    Cognitive Level: Application             REF:    p. 42                OBJ:    6

TOP:    Assisting with Lumbar Puncture        KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. In order to prepare a child for a lumbar puncture, the nurse would place the child in which position?
a. Supine
b. Side-lying in the center of the table with knees flexed
c. Seated with legs dangling and neck flexed
d. Side-lying with neck and knees held in flexed position

 

 

ANS:   D

The nurse can place the child in either a side-lying position with knees flexed, or a seated position with the back curved on the edge of the examination table.

 

DIF:    Cognitive Level: Application             REF:    p. 42                OBJ:    6

TOP:    Assisting with Lumbar Puncture        KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Following a successful lumbar puncture, in order to avoid post-procedure discomfort for the patient, the nurse should:
a. Ask the parents to keep the child flat for several hours
b. Encourage the child to begin ambulation as soon as possible
c. Place the child in the high Fowler’s position for several hours
d. Place the child in the semi-Fowler’s position with knees flexed for several hours

 

 

ANS:   A

The child is instructed to lay flat for a certain amount of time in order to decrease the chance of developing a spinal headache. Ambulation and a high Fowler’s position would increase the likelihood of having a spinal headache.

 

DIF:    Cognitive Level: Application             REF:    p. 42                OBJ:    6

TOP:    Assisting with Lumbar Puncture        KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse sees an order to give 500 mg of an oral suspension of Ampicillin to a child who weighs 22 pounds. After the nurse has calculated the dose based on the child’s weight and sees that the dose should be 50 mg/kg/day, the nurse should:
a. Tell the charge nurse that the dose seems too high
b. Call the physician to clarify the order
c. Give the ordered dose
d. Ask the parents if the child has taken this much drug previously

 

 

ANS:   C

The nurse should calculate the child’s weight in kilograms and compare with the recommended dose. 22 pounds child weight = 10 kilograms; 10 kilograms multiplied by 50 mg = 500 mg. The ordered dose should be given.

 

DIF:    Cognitive Level: Application             REF:    p. 42                OBJ:    7

TOP:    Administering Medication                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse has drawn up 5 units of insulin to give to an 8-year-old. As a safety precaution prior to giving the drug, the nurse should:
a. Ask the parent if the child has ever had an insulin reaction
b. Check the child’s blood sugar
c. Verify the dose with another nurse
d. Chart the administration of the drug

 

 

ANS:   D

Prior to giving drugs such as digoxin, insulin, heparin, and narcotics, the dose is verified by another nurse. There is no need to check the blood sugar at this time. Drugs are never charted until they are actually given.

 

DIF:    Cognitive Level: Application             REF:    p. 44                OBJ:    7

TOP:    Administering Medication                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse brings the medication into a child’s room for administration. The intervention that will ensure safe administration of this medication is:
a. Call the child by name to verify the patient’s identity
b. Verify the patient’s identity with the hospital identification band for child’s birth date
c. Inform the parent about the side effects of the drug
d. Ask another nurse to verify the child’s identity

 

 

ANS:   B

The nurse should not rely on the child for verification of identity. The identity should be confirmed by comparing the hospital identification band and a second identifier, such as birth date or room number.

 

DIF:    Cognitive Level: Application             REF:    p. 44                OBJ:    7

TOP:    Administering Medication                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse caring for a 2-month-old baby uses a(n) __________ to administer a very small dose of oral medication that is in a suspension.
a. Oral syringe
b. Calibrated cup
c. Teaspoon
d. Nipple

 

 

ANS:   A

The nurse would use an oral syringe, because it is the most accurate. Teaspoons are often inaccurate and do not hold a standard amount. It is hard to be accurate with a small dose using a calibrated cup. The nipple is useful but does not have anything to do with accuracy.

 

DIF:    Cognitive Level: Application             REF:    p. 44                OBJ:    7

TOP:    Medication Administration                KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. An intramuscular (IM) injection is ordered for a 6-month-old child. The nurse should select the injection site of:
a. Dorsogluteal
b. Ventrogluteal
c. Vastus lateralis
d. Deltoid

 

 

ANS:   C

The nurse would choose the vastus lateralis because it is well-developed at birth, it is the largest muscle mass, and it has the fewest vessels and nerves. The dorsogluteal is not fully developed until the child has walked for 1 to 2 years. The ventrogluteal should not be used until 18 months. The deltoid cannot be used for large volumes of medication or for medications that need to be administered into the deep muscle mass.

 

DIF:    Cognitive Level: Application             REF:    p. 47                OBJ:    8

TOP:    Intramuscular Injections                     KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse giving an intramuscular (IM) dose of 2 mL to a 6-month-old child should:
a. Inject the entire amount in the ventrogluteal muscle
b. Give the medication in divided doses in each deltoid
c. Inject 1 mL into each vastus lateralis
d. Divide the dose, and give 1 mL injections 1 hour apart

 

 

ANS:   C

The nurse should divide the dose and give the maximum 1 mL in each vastus lateralis.

 

DIF:    Cognitive Level: Application             REF:    p. 47                OBJ:    8

TOP:    Intramuscular Injections                     KEY:   Nursing Process Step: Application

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is aware that an IV antibiotic medication should infuse in no longer than:
a. 15 minutes
b. 30 minutes
c. 45 minutes
d. 60 minutes

 

 

ANS:   D

An antibiotic medication should infuse in no longer than 60 minutes.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 49                OBJ:    9

TOP:    Intravenous Medication                     KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. An infant with diarrhea is dehydrated. IV fluids have been ordered to restore fluid balance. The most effective device used to prevent fluid overload is:
a. A precision-controlled syringe pump
b. A piggyback setup
c. A tunneled IV catheter
d. A 15-drop infusion set

 

 

ANS:   A

A syringe or other in-line volume-control device is often used because they hold a limited amount of fluid. Only that fluid can be administered at one time. A piggyback setup would be used to infuse a dose of medication, not a continuous infusion. Neither a tunneled catheter nor a 15-drop infusion set would protect the child from fluid overload.

 

DIF:    Cognitive Level: Application             REF:    p. 49                OBJ:    9

TOP:    Parenteral Fluids                                KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse monitoring the TPN infusion for a small child assesses that the infusion is behind. The nurse should:
a. Speed up the infusion to catch up
b. Notify the charge nurse
c. Stop the infusion, and notify the charge physician
d. Give the child extra fluids to make up for the deficit

 

 

ANS:   B

TPN must be monitored carefully. Speeding up an infusion can cause hyperglycemia. The infusion should not be stopped. The charge nurse should be notified.

 

DIF:    Cognitive Level: Application             REF:    p. 50                OBJ:    9

TOP:    Total Parenteral Nutrition                  KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Following a gavage feeding, a 4-year-old child should be positioned:
a. In a high Fowler’s position to prevent aspiration
b. In a semi-Fowler’s position with knees flexed to prevent cramping
c. On the right side to aid in stomach emptying
d. On the left side to slow stomach emptying

 

 

ANS:   C

After a gavage feeding, the child is positioned on the right side to aid in stomach emptying.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 51                OBJ:    10

TOP:    Gavage Feedings                                KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When the nurse is instilling drops into the ear of a 2-year-old, the nurse should:
a. Pull the earlobe up
b. Chill the drops prior to administration
c. Assist the child to sit upright after instillation
d. Draw the earlobe down and back to straighten the ear canal

 

 

ANS:   D

For a child younger than 3 years of age, the earlobe is drawn down and back to straighten the ear canal and allow the drops to enter the ear canal. The child should be left in a supine or side-lying position while the drops are absorbed. The drops should be warmed.

 

DIF:    Cognitive Level: Application             REF:    p. 46                OBJ:    7

TOP:    Topic: Administration of Eardrops    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The nurse modifies the technique of administering eyedrops for a 1-month-old infant by:
a. Placing the drops in the nasal corner of the eyelid
b. Asking assistance of a coworker to hold the lids open
c. Grasping the eyelashes and placing the drops under the lid
d. Applying the drops from a moistened cotton ball

 

 

ANS:   A

Because infants clench their eyes shut, the drops can be placed in the nasal corner of the eye so when the child opens the eyes the medication flows onto the conjunctiva.

 

DIF:    Cognitive Level: Application             REF:    p. 47                OBJ:    7

TOP:    Topic: Infant Eyedrops                      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

COMPLETION

 

  1. Carrying out procedures in the least stressful manner to the child is called ___________.

 

ANS:

Atraumatic care

Considering the least painful or stressful method to complete a procedure is classified as atraumatic care.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 33                OBJ:    2

TOP:    Preparation for Procedures                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Psychosocial Integrity: Basic Care and Comfort

 

  1. When parenteral fluids have escaped into the surrounding tissue, the nurse would document and report that ___________ had occurred.

 

ANS:

Extravasation or infiltration

Extravasation is the term for escaped parenteral fluid that has entered the surrounding tissue.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 50                OBJ:    1

TOP:    Extravasation                                     KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A catheter threaded into the superior vena cava for the purpose of parenteral nutrition (TPN) is referred to as a(n) ___________.

 

ANS:

PICC or peripherally inserted central catheter

A PICC is inserted into the antecubital area and threaded into the superior vena cava, and it can be used for long-term parenteral therapy.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 50                OBJ:    9

TOP:    PICC               KEY:   Nursing Process Step: N/A                MSC:   NCLEX: N/A

 

  1. For a child who weighs 32 pounds, what is the maximum pediatric dose for a medication that is recommended to be given at 35 mg/kg/day?

 

ANS:

507.5 mg

RAT: 32 pounds divided by 2.2 = 14.5 kilograms; 14.5 kilograms multiplied by 35 = 507.5 mg.

 

DIF:    Cognitive Level: Application             REF:    p. 42                OBJ:    7

TOP:    Topic: Dose calculation                      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. When selecting a cuff for a child, the nurse should confirm that the width of the cuff covers approximately ____________ of the upper arm.

 

ANS:

Two thirds

A cuff that is too large will give an erroneously low reading.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 60                OBJ:    14

TOP:    Blood Pressure Cuff Width               KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When preparing an enema solution for a child younger than 2 years of age, the total amount of fluid should not exceed ____________.

 

ANS:

240 mL

Children younger than 2 years of age should not receive more than 240 mL of fluid in an enema solution.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 51                OBJ:    2

TOP:    Enema Volume                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. The nurse giving an allergy desensitization injection to a well-fed 8-month-old child in a subcutaneous injection would: (Select all that apply.)
a. Select a 23-gauge needle
b. Inject at a 90-degree angle
c. Gently aspirate before injecting the medicine
d. Give a maximum of 1 mL
e. Give the injection in the abdomen

 

 

ANS:   B, E

A dose of no more than 0.05 mL can be delivered with a 25- to 27-gauge needle, usually in the abdomen at a 90-degree angle without aspiration.

 

DIF:    Cognitive Level: Application             REF:    p. 35                OBJ:    8

TOP:    Topic: Subcutaneous Injections         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse would assess a 5-year-old patient who had a lumbar puncture completed 30 minutes ago for: (Select all that apply.)
a. Drainage at the puncture site
b. Evidence of headache
c. Elevation of temperature
d. Allergic skin reaction
e. Gastric distress

 

 

ANS:   A, B, C

Following a lumbar puncture, the patient should be assessed for drainage at the puncture site, evidence of post-puncture headache, or elevation of temperature. Allergic skin reaction and gastric distress are not associated with post-lumbar puncture concerns.

 

DIF:    Cognitive Level: Application             REF:    p. 48                OBJ:    6

TOP:    Assisting with Lumbar Puncture        KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Considerations about possible risk factors of giving medications to children include: (Select all that apply.)
a. Smaller body mass of a child
b. Immaturity of body systems
c. Need for individuality of dose
d. High toxicity of many modern drugs
e. Unavailability of useful drug references

 

 

ANS:   A, B, C, D

Medicating small children is hazardous because of their smaller body mass, the immaturity of their body systems, the need for individualizing doses, and the high toxicity of many modern drugs. Many drug references are available.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 42                OBJ:    7

TOP:    Administering Medication                 KEY:   Nursing Process Step: Intervention

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The signs that indicate the need for tracheal suctioning in a 3-month-old child are:
a. Coughing
b. Crust around the tracheostomy tube
c. A bubbling sound during respiration
d. Noisy breathing
e. Moisture on a dressing under the tracheostomy tube

 

 

ANS:   A, C, D

Coughing, a bubbling sound during respiration, and noisy breathing are indicators of the need for tracheostomy suctioning. Crust on the tube and a moist dressing can be remedies when the tube is cleaned and are not indicators of obstruction.

 

DIF:    Cognitive Level: Application             REF:    p. 42                OBJ:    11

TOP:    Suctioning       KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

OTHER

 

  1. Place the steps of the infant bath in the correct sequence:
  2. Apply water and shampoo to the head, and shampoo the hair/scalp
  3. Fill the tub, and test the water for appropriate warmth
  4. Remove secretions from the baby’s eyes
  5. Bathe the trunk and limbs
  6. Wash the perineal area

 

ANS:

B, C, A, D, E

The water is run and tested for appropriate warmth (100° F). The eyes are cleansed using a separate cotton ball for each eye, the face is washed, the hair/scalp is shampooed, the trunk and limbs are washed, the perineum is washed, and the baby is wrapped in a towel to dry.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 54                OBJ:    3

TOP:    Topic: Bathing Infant                         KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

Price: Pediatric Nursing, 11th Edition

 

Chapter 17: Musculoskeletal Disorders

 

Testbank

 

MULTIPLE CHOICE

 

  1. The nurse understands that a difference in the child’s skeletal system as compared to an adult’s is:
a. The thick periosteum assists in repair of fractures
b. Growth is not affected by fractures
c. Bone overgrowth in healing fractures is uncommon
d. The child’s bones are less porous than an adult’s bones

 

 

ANS:   A

Thick, rich periosteum assists in rapid repair of a fracture in a child. Children’s fractures can result in overgrowth. The child’s bones are more porous and less dense than an adult’s bones.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 318              OBJ:    2

TOP:    Periosteum      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse writes out a schedule for the casting procedures to correct a clubfoot, which would be:
a. At 5-day intervals for the first 4 weeks
b. At 1-week intervals for the first 6 weeks
c. At 10-day intervals for the first 8 weeks
d. At 2-week intervals for the first 10 weeks

 

 

ANS:   B

The casting is repeated every week for the first 6 weeks and then at 1- to 2-week intervals until a more anatomic position has been achieved.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 319              OBJ:    N/A

TOP:    Casting for Clubfoot                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse clarifies that the brace applied to help correct a clubfoot should be worn:
a. Only at night
b. 6 hours at a time
c. 8 hours on, and then 2 hours off
d. 23 hours per day

 

 

ANS:   D

The brace that is applied in an attempt to correct a clubfoot is worn 23 hours per day for an extended amount of time.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 319              OBJ:    N/A

TOP:    Brace for Clubfoot                             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The goal of clubfoot repair is to have a corrected foot by the time the child is:
a. 6 months of age
b. 9 months of age
c. 12 months of age
d. 18 months of age

 

 

ANS:   C

The goal of clubfoot repair is to be completed by the time the child is 12 months of age so the child can use normal shoes when learning to walk.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 319              OBJ:    N/A

TOP:    Clubfoot Correction                           KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. When the 8-month-old child who has had a plaster cast applied becomes fussy and irritable, the mother asks how long it will take the cast to dry. The nurse’s response will be based on the knowledge that plaster casts dry in about:
a. 2 hours
b. 10 hours
c. 18 hours
d. 24 hours

 

 

ANS:   D

Plaster casts take 24 to 72 hours to dry.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 319              OBJ:    N/A

TOP:    Plaster             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When caring for a child with a broken leg who is in a wet plaster cast, the nurse should:
a. Cover the cast to keep from chilling the child
b. Rest the cast on the foot of the bed to relieve the weight
c. Handle the cast with the palms of the hands
d. Avoid moving the child until the cast is dry

 

 

ANS:   C

The cast should be handled with the palms of the hands, not the fingers, to keep from making indentations. For the same reason, the cast is not propped on a hard surface. The child should be repositioned every 2 hours. The cast should not be covered as it will delay drying.

 

DIF:    Cognitive Level: Application             REF:    p. 319              OBJ:    N/A

TOP:    Plaster Cast     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When the 8-year-old complains of the rough edges of the cast cutting her fingers, the nurse should:
a. Tape adhesive over the fingers
b. Shake a small amount of powder into the cast
c. Soften the edge of the cast with warm oil and remold the cast
d. Apply adhesive “petals” around the edge of the cast

 

 

ANS:   D

“Petaling” a cast with adhesive tape will reduce the discomfort of rough edges against the patient’s skin.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 318              OBJ:    N/A

TOP:    Petaling           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When the child comes back from surgery after the correction of a clubfoot, the nurse assesses a discolored area on the cast. The initial intervention of the nurse should be:
a. Make a note in the patient record
b. Notify the charge nurse
c. Circle the area and write the time
d. Elevate the limb

 

 

ANS:   C

The initial intervention should be to circle the area and write the time on the cast in order to evaluate if the area changes in size. After this initial intervention, the limb is elevated, the charge nurse or physician is notified, and a note is made in the patient record.

 

DIF:    Cognitive Level: Application             REF:    p. 318              OBJ:    N/A

TOP:    Cast Assessment                                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. The nurse recognizes the Trendelenburg gait as a diagnostic sign of:
a. Legg-Calvé-Perthes disease
b. Duchenne muscular dystrophy
c. Developmental dysplasia of the hip (DDH)
d. Scoliosis

 

 

ANS:   C

The Trendelenburg gait is the diagnostic gait of a child with developmental dysplasia of the hip (DDH).

 

DIF:    Cognitive Level: Comprehension       REF:    p. 320              OBJ:    N/A

TOP:    Developmental Dysplasia of the Hip

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains that the desired outcome of the treatments to correct developmental dysplasia of the hip is:
a. Stimulate ossification of the head of the femur
b. Deepen the acetabulum
c. Surgically rebuild the acetabulum
d. Prevent the femur from pressing into the acetabulum

 

 

ANS:   B

Deepening the acetabulum by pressing the head of the femur into it will deepen the joint and allow the head of the femur to be stabilized. This is accomplished by the use of a pillow splint or a Pavlik harness.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 320              OBJ:    N/A

TOP:    Developmental Dysplasia of the Hip

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse giving tips to parents of a child in the Pavlik harness would suggest that to prevent chafing they should:
a. Use powder in the diaper area
b. Dress the baby in a T-shirt and long socks
c. Take the harness off every 2 hours
d. Use lanolin-based ointment on the legs

 

 

ANS:   B

The use of a T-shirt and long socks will help relieve chafing as the baby will be in the harness full-time except for diaper changes.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 321              OBJ:    3

TOP:    Pavlik Harness                                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse recognizes that a child with cerebral palsy who has jerky movements and scissoring of the legs has the type of cerebral palsy classified as:
a. Mixed
b. Athetoid
c. Spastic
d. Dyskinetic

 

 

ANS:   C

Jerky movements and scissoring of the legs are characteristic of spastic cerebral palsy.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 323              OBJ:    N/A

TOP:    Spastic Type of Cerebral Palsy          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse caring for a child with Duchenne muscular dystrophy notes a characteristic manifestation, which is that the child:
a. Ambulates by holding onto furniture
b. Exhibits atrophy of the calf muscles
c. Falls frequently and is clumsy
d. Has delayed fine-motor development

 

 

ANS:   C

The child with Duchenne muscular dystrophy is clumsy and falls frequently because of pseudohypertrophy of the calves and contractures of the ankles and hips.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 324              OBJ:    4

TOP:    Duchenne Muscular Dystrophy         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is aware that an activity that will help delay muscle atrophy for a child with Duchenne muscular dystrophy is:
a. Progressive weight lifting
b. Riding a seesaw
c. Swimming
d. Working on a trampoline

 

 

ANS:   C

Swimming is helpful to promote range of motion and delay muscle atrophy.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 325              OBJ:    4

TOP:    Duchenne Muscular Dystrophy         KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is concerned about the fracture across the epiphyseal plate of a 9-year-old child because such a fracture could:
a. Interfere with bone growth
b. Progress into osteomyelitis
c. Cause a mis-union of the bone ends
d. Lead to a long recovery period

 

 

ANS:   A

Fractures that disturb the epiphyseal plate can affect bone growth.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 325              OBJ:    6

TOP:    Pediatric Fractures                             KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A 17-year-old whose legs were crushed in a motorcycle accident has come to the emergency department. While waiting for x-rays, the patient begins to sweat and have labored breathing. The nurse suspects that the patient has had:
a. An anxiety attack
b. The onset of shock
c. A fat embolism
d. An aspiration of blood

 

 

ANS:   C

A fat embolism occurs as fat escapes from the bone marrow. The signs of an embolism are labored respirations and a possible change in level of consciousness. This condition should be reported immediately.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 325              OBJ:    6

TOP:    Fat Embolism                                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains that Russell traction is a type of skin traction that:
a. Subluxates the tibia
b. Does not interfere with range of motion
c. Prevents the knee from flexing
d. Supplies continuous pull in two directions

 

 

ANS:   D

Russell traction is skin traction (similar to Buck’s traction) with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full range of motion, the patient can change position without disrupting the continuous pull in two directions.

 

DIF:    Cognitive Level: Application             REF:    p. 327              OBJ:    6

TOP:    Russell Traction                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse assesses that a 5-year-old who is in Russell traction is holding his left elbow with the right hand and seems to be in pain. The child will not use the left arm to reach for a toy or a glass of juice. Based on these assessments, the nurse suspects the child has suffered:
a. Muscle spasms
b. A pulled muscle
c. A dislocated elbow
d. Osteomyelitis

 

 

ANS:   C

Dislocated elbows in children who are in traction are not uncommon. The injury occurs when the child uses a twisting motion of the lower arm and hand, which dislocates the radial head.

 

DIF:    Cognitive Level: Application             REF:    p. 329              OBJ:    N/A

TOP:    Dislocated Elbow                               KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease.

 

  1. The nurse caring for a child in traction with a broken leg should add to the plan of care an intervention to prevent constipation, such as:
a. Offering different fluids during the day
b. Encouraging the intake of milk products
c. Avoiding fruits
d. Limiting foods high in fiber

 

 

ANS:   A

Offering fluids frequently, providing fluids at the bedside, and encouraging foods high in fiber will help prevent constipation.

 

DIF:    Cognitive Level: Application             REF:    p. 329              OBJ:    5

TOP:    Prevention of Constipation                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. In discussing the long-term effects of Legg-Calvé-Perthes disease, the nurse would include the information that:
a. There are no long-term effects
b. The disease is likely to recur
c. Deformity of the femoral head may result in arthritis
d. There is a risk of osteogenic sarcoma in adulthood

 

 

ANS:   C

Deformity of the femoral head can cause problems such as arthritis in later life.

 

DIF:    Cognitive Level: Application             REF:    p. 329              OBJ:    7

TOP:    Legg-Calvé-Perthes disease               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. When a 3-year-old girl is diagnosed with neuromuscular scoliosis, the nurse explains that the spinal curvature defect is usually caused by:
a. Juvenile rheumatoid arthritis
b. Poor posture
c. Heredity
d. Myelomeningocele

 

 

ANS:   D

Neuromuscular scoliosis is the result of a disease such as cerebral palsy or spina bifida.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 332              OBJ:    N/A

TOP:    Scoliosis          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse assessing a preadolescent child for scoliosis would:
a. Ask the child to bend forward at the waist, and then observe the child’s back for asymmetry
b. Observe the gait while the child is walking forward heel to toe
c. Have the child flex the knees and look for uneven knee height
d. Look at the child’s shoulders and hips while fully clothed

 

 

ANS:   A

The nurse looks at the back, as the child bends forward, for general body alignment and asymmetry.

 

DIF:    Cognitive Level: Application             REF:    p. 333              OBJ:    N/A

TOP:    Scoliosis          KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse providing instructions to an adolescent who has been fitted with a Milwaukee brace would suggest:
a. Wearing the brace directly against the skin
b. Wearing the brace over regular clothing
c. Wearing the brace over a T-shirt 23 hours per day
d. Removing the brace before sleeping

 

 

ANS:   C

A Milwaukee brace is worn approximately 23 hours per day over a T-shirt that protects the skin. Some experts believe the same therapeutic outcome will occur with only 16 hours of wear per day.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 334              OBJ:    8

TOP:    Milwaukee Brace                               KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

COMPLETION

 

  1. The nurse informs the parents of a child with a clubfoot that the ___________ method is the current method of manipulation.

 

ANS:

Ponseti

The Ponseti method is the current method employed for manipulation of a clubfoot. The foot is gently manipulated into better alignment and then casted. These steps are repeated until the foot is straightened.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 319              OBJ:    N/A

TOP:    Manipulation                                      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is aware that in the condition of developmental dysplasia of the hip (DDH), the deformity is caused when the head of the femur does not seat itself in the __________.

 

ANS:

Acetabulum

The head of the femur in a child with DDH is displaced from the shallow acetabulum.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 318              OBJ:    N/A

TOP:    Developmental Dysplasia of the Hip

KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When the pediatrician abducts the child’s femur, the nurse hears an audible click, which is the diagnostic sign called______________.

 

ANS:

Ortolani’s sign

Ortolani’s sign is the audible click heard when the femur is snapped back into the acetabulum.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 320              OBJ:    1

TOP:    Ortolani’s Sign                                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The child with Duchenne muscular dystrophy must push on his or her legs and “walk up the leg” in order to rise to a standing position. The nurse recognizes this characteristic behavior as the __________ maneuver.

 

ANS:

Gower

The Gower maneuver is a characteristic method of rising from the floor by “walking” up the legs to push the upper body erect.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 324              OBJ:    4

TOP:    Gower Maneuver                               KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The child with cerebral palsy who exhibits slow writhing movements that increase during periods of emotional stress is showing the characteristics of __________ cerebral palsy.

 

ANS:

Athetoid

The athetoid or dyskinetic type of cerebral palsy exhibits slow writhing movements that increase during periods of emotional stress.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 325              OBJ:    N/A

TOP:    Athetoid Cerebral Palsy                     KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The five Ps of compartment syndrome are: (1)_____(2)_____(3)_____(4)_____(5)_____

 

ANS:

Pain, pallor, pulselessness, paresthesia, and paralysis

Compartment syndrome can occur as a result of pressure on tissues resulting from edema or swelling. This pressure compromises the circulation and results in pain, pallor, pulselessness, paresthesia, and paralysis distal to the swelling. This is a medical emergency.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 329              OBJ:    6

TOP:    Compartment Syndrome                    KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. The nurse is aware that the musculoskeletal system of the child is composed of: (Select all that apply.)
a. Major blood vessels
b. Bones
c. Joints
d. Muscle
e. Cartilage

 

 

ANS:   B, C, D, E

The musculoskeletal system is composed of bones, joints, muscle, and cartilage.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 318              OBJ:    2

TOP:    Musculoskeletal System                     KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse reassures a worried parent that the child’s fracture will heal quickly because the rich periosteum provides: (Select all that apply.)
a. Blood vessels
b. Calcium
c. Nerve fibers
d. Lymphatic vessels
e. Fat cells

 

 

ANS:   A, C, D

The periosteum contains blood vessels, nerve fibers, and lymphatic vessels.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 318              OBJ:    2

TOP:    Periosteum      KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse is glad to see that the 3-month-old is going to be casted with a synthetic cast because synthetic casts: (Select all that apply.)
a. Dry quicker
b. Do not cause circulatory problems
c. Are lighter
d. Allow for greater mobility
e. Can be modified and reused

 

 

ANS:   A, C, D

Synthetic casts made of fiberglass or polyurethane dry in less than 30 minutes and are lighter and allow for more mobility.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 319              OBJ:    N/A

TOP:    Synthetic Casts                                  KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Signs and symptoms that would indicate that a leg cast has interfered with the circulation of a limb would be: (Select all that apply.)
a. Pallor
b. Pain
c. Weak pulse
d. Warmth in toes
e. Paralysis

 

 

ANS:   A, B, C, E

Pallor, pain, weakness or lack of pulse, burning, coldness, paralysis, and numbness are all indicators of an embarrassed circulation. Warm toes indicate adequate circulation. The cast may need to be slit or removed entirely.

 

DIF:    Cognitive Level: Application             REF:    p. 319              OBJ:    N/A

TOP:    Circulatory Checks                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse in a well-child clinic would suspect a child to have developmental dysplasia of the hip (DDH) when diagnostic characteristics are assessed such as: (Select all that apply.)
a. A narrow pelvis
b. Asymmetrical gluteal folds
c. The foot on the affected side turns out
d. When legs are flexed, one knee is lower than the other
e. The foot on the affected side is cooler

 

 

ANS:   B, D

Indications of DDH that are characteristic are asymmetric gluteal folds on the affected side, and when the legs are flexed the knee on the affected side is lower than the other.

 

DIF:    Cognitive Level: Application             REF:    p. 320              OBJ:    N/A

TOP:    Developmental Dysplasia of the Hip

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse instructing parents in the care of a child in a body spica cast would include the information to: (Select all that apply.)
a. Use firm pillows in curvatures of the cast for support
b. Elevate the child’s head and shoulders with pillows
c. Tuck a disposable diaper under the buttocks to prevent soiling the cast
d. Use a bib to keep food from falling into the cast
e. Relieve itching by blowing warm air from a hair dryer into the cast

 

 

ANS:   A, C, D

Pillows should be used under curvatures of the cast; the head and shoulders should not be elevated on pillows as it may cause respiratory difficulty. A disposable diaper tucked into the buttock opening of the cast can prevent soiling the cast with feces. A bib will keep food from entering the cast. Cool air is helpful with itching.

 

DIF:    Cognitive Level: Application             REF:    p. 321              OBJ:    5

TOP:    Spica Cast       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is aware that some causes of cerebral palsy include: (Select all that apply.)
a. Perinatal cerebral hemorrhage
b. Prolonged labor
c. Maternal use of tobacco
d. Maternal exposure to rubella
e. Sexually transmitted diseases in the mother

 

 

ANS:   A, B, D

Hemorrhage, prolonged labor, and exposure to infectious diseases such as rubella are recognized causes of cerebral palsy.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 322              OBJ:    N/A

TOP:    Cerebral Palsy                                    KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains to the parents of a child with Duchenne muscular dystrophy that treatment for this horrible disease is centered on: (Select all that apply.)
a. Progressive strengthening exercises
b. Passive exercises to prevent contractures
c. Surgery for joint contractures
d. Aggressive programs for weight control
e. Bracing for limb stability

 

 

ANS:   B, C, D, E

Progressive strengthening exercises are not part of the treatment plan for Duchenne muscular dystrophy.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 325              OBJ:    4

TOP:    Treatment for Duchenne Muscular Dystrophy

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The school nurse is called to the schoolyard where there is a child on the ground with an obvious simple fracture of the tibia. The nurse should: (Select all that apply.)
a. Call for assistance to carry the child into the building
b. Immobilize the limb with rolled newspapers or magazines
c. Apply ice cubes directly to the swelling
d. Call EMS
e. Immobilize the joints at the knee and ankle

 

 

ANS:   B, D, E

The limb should be immobilized by a splint made of anything handy, and the joints above and below the suspected fracture should be immobilized as well. Ice should be collected in a cloth, but not put directly to the skin. Call EMS.

 

DIF:    Cognitive Level: Application             REF:    p. 325              OBJ:    6

TOP:    Skeletal           KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. The nurse reviews the general rules for maintaining adequate tractions, which include: (Select all that apply.)
a. Ropes to weights in the grooves of the pulleys
b. The child should be kept in anatomic alignment
c. Ace bandages should be wrapped tightly
d. Weights should hang free
e. Traction can be removed to facilitate care

 

 

ANS:   A, B, D

Ropes should be in the pulleys, the child should be kept in alignment, the weights should hang free, and the traction should be continuous. The bandages should not be wrapped tightly, to prevent obstruction of circulation, and the traction should not be interrupted.

 

DIF:    Cognitive Level: Application             REF:    p. 329              OBJ:    6

TOP:    Traction           KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort