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Wong’s Nursing Care of Infants and Children 10th Edition by Marilyn J. Hockenberry – Test Bank 

 

Chapter 05: Pain Assessment and Management in Children

 

MULTIPLE CHOICE

 

  1. Which is the most consistent and commonly used data for assessment of pain in infants?
a. Self-report
b. Behavioral
c. Physiologic
d. Parental report

 

 

ANS:  B

Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

 

DIF:    Cognitive Level: Understanding     REF:   p. 152

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group?
a. “No hurt.”
b. “Red pain.”
c. “Zero hurt.”
d. “Least pain.”

 

 

ANS:  A

“No hurt” is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. “Least pain” is less concrete than “no hurt.”

 

DIF:    Cognitive Level: Applying              REF:   p. 154

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is an important consideration when using the FACES pain rating scale with children?
a. Children color the face with the color they choose to best describe their pain.
b. The scale can be used with most children as young as 3 years.
c. The scale is not appropriate for use with adolescents.
d. The FACES scale is useful in pain assessment but is not as accurate as physiologic responses.

 

 

ANS:  B

The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The child’s estimate of the pain should be used. The physiologic measures may not reflect more long-term pain.

 

DIF:    Cognitive Level: Applying              REF:   p. 154

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What describes nonpharmacologic techniques for pain management?
a. They may reduce pain perception.
b. They usually take too long to implement.
c. They make pharmacologic strategies unnecessary.
d. They trick children into believing they do not have pain.

 

 

ANS:  A

Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child’s pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.

 

DIF:    Cognitive Level: Analyzing            REF:   pp. 163-164   TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain?
a. Tactile stimulation
b. Commercial warm packs
c. Doing procedure during infant sleep
d. Oral sucrose and nonnutritive sucking

 

 

ANS:  D

Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 165            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?
a. The child will continue to sleep and be pain free.
b. Parents cannot administer additional medication with the button.
c. The pump can deliver baseline and bolus dosages.
d. There is a high risk of overdose, so monitoring is done every 15 minutes.

 

 

ANS:  C

The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year-old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

 

DIF:    Cognitive Level: Applying              REF:   p. 176

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?
a. Codeine sulfate (Codeine)
b. Morphine (Roxanol)
c. Methadone (Dolophine)
d. Meperidine (Demerol)

 

 

ANS:  B

The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 176

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which?
a. Give only an opioid analgesic at this time.
b. Increase dosage of analgesic until the child is adequately sedated.
c. Plan a preventive schedule of pain medication around the clock.
d. Give the child a clock and explain when she or he can have pain medications.

 

 

ANS:  C

For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the child’s attention on how long he or she will need to wait for pain relief.

 

DIF:    Cognitive Level: Implementation    REF:   p. 176            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse’s response should be based on which characteristic about preterm infants’ pain?
a. They may react to painful stimuli but are unable to remember the pain experience.
b. They perceive and react to pain in much the same manner as children and adults.
c. They do not have the cortical and subcortical centers that are needed for pain perception.
d. They lack neurochemical systems associated with pain transmission and modulation.

 

 

ANS:  B

Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 153

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. A preterm infant has just been admitted to the neonatal intensive care unit. The infant’s parents ask the nurse about anesthesia and analgesia when painful procedures are necessary. What should the nurse’s explanation be?
a. Nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli.
b. The risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief.
c. Neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences.
d. Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates.

 

 

ANS:  D

Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 185

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which?
a. Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure.
b. Use a combination of fentanyl and midazolam for conscious sedation.
c. Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure.
d. Apply a transdermal fentanyl (Duragesic) “patch” immediately before the procedure.

 

 

ANS:  B

A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 185

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. What is a significant common side effect that occurs with opioid administration?
a. Euphoria
b. Diuresis
c. Constipation
d. Allergic reactions

 

 

ANS:  C

Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.

 

DIF:    Cognitive Level: Remembering      REF:   p. 171            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first?
a. Administer naloxone (Narcan).
b. Discontinue the IV infusion.
c. Discontinue morphine until the child is fully awake.
d. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Applying              REF:   p. 180

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching?
a. “With minimal sedation, the patient’s respiratory efforts are affected, and cognitive function is not impaired.”
b. “With general anesthesia, the patient’s airway cannot be maintained, but cardiovascular function is maintained.”
c. “During deep sedation, the patient can be easily aroused by loud verbal commands and tactile stimulation.”
d. “During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation.”

 

 

ANS:  D

When discussing levels of sedation, the participants should understand that during moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by painful stimuli; the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia, the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 184

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is planning to administer a nonopioid for pain relief to a child. Which timing should the nurse plan so the nonopioid takes effect?
a. 15 minutes until maximum effect
b. 30 minutes until maximum effect
c. 1 hour until maximum effect
d. 1 1/2 hours until maximum effect

 

 

ANS:  C

Nonsteroidal antiinflammatory drugs (NSAIDs) can provide safe and effective pain relief when dosed at appropriate levels with adequate frequency. Most NSAIDs take about 1 hour for effect, so timing is crucial.

 

DIF:    Cognitive Level: Applying              REF:   p. 171            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route?
a. Less expensive than oral medications
b. Produces a first-pass effect through the liver
c. Does not need to be administered frequently
d. Provides most rapid onset of effect, usually in about 5 minutes

 

 

ANS:  D

The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the first-pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control.

 

DIF:    Cognitive Level: Applying              REF:   p. 176            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is teaching the parents of a child with recurrent headaches methods to modify behavior patterns that increase the risk of headache. Which statement by the parents indicates understanding the teaching?
a. “We will allow the child to miss school if a headache occurs.”
b. “We will respond matter-of-factly to requests for special attention.”
c. “We will be sure to give much attention to our child when a headache occurs.”
d. “We will be sure our child doesn’t have to perform at a band concert if a headache occurs.”

 

 

ANS:  B

To modify behavior patterns that increase the risk of headache or reinforce headache activity, the nurse instructs the parents to avoid giving excessive attention to their child’s headache and to respond matter-of-factly to pain behavior and requests for special attention. Parents learn to assess whether the child is avoiding school or social performance demands because of headache.

 

DIF:    Cognitive Level: Applying              REF:   p. 186

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Which is a complication that can occur after abdominal surgery if pain is not managed?
a. Atelectasis
b. Hypoglycemia
c. Decrease in heart rate
d. Increase in cardiac output

 

 

ANS:  A

Pain associated with surgery in the abdominal region (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications such as pneumonia and atelectasis is high. Severe postoperative pain also results in sympathetic overactivity, which leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. Hypoglycemia, decreases in heart rate, and increases in cardiac output are not complications of poor pain management.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 185

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A burn patient is experiencing anxiety over dressing changes. Which prescription should the nurse expect to be ordered to control anxiety?
a. Lorazepam (Ativan)
b. Oxycodone (OxyContin)
c. Fentanyl (Sublimaze)
d. Morphine Sulfate (Morphine)

 

 

ANS:  A

A benzodiazepine such as lorazepam is prescribed as an antianxiety agent. Oxycodone, fentanyl, and morphine sulfate are opioid analgesics.

 

DIF:    Cognitive Level: Applying              REF:   p. 186            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety?
a. Lorazepam (Ativan)
b. Gabapentin (Neurontin)
c. Hydromorphone (Dilaudid)
d. Morphine sulfate (MS Contin)

 

 

ANS:  B

Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.

 

DIF:    Cognitive Level: Applying              REF:   p. 189            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which are components of the FLACC scale? (Select all that apply.)
a. Color
b. Capillary refill time
c. Leg position
d. Facial expression
e. Activity

 

 

ANS:  C, D, E

Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC scale.

 

DIF:    Cognitive Level: Understanding     REF:   p. 154

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.)
a. Color
b. Moro reflex
c. Oxygen saturation
d. Posture of arms and legs
e. Sleeplessness
f. Facial expression

 

 

ANS:  C, E, F

Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.

 

DIF:    Cognitive Level: Applying              REF:   p. 159

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Which coanalgesics should the nurse expect to be prescribed for pruritus? (Select all that apply.)
a. Naloxone (Narcan)
b. Inapsine (Droperidol)
c. Hydroxyzine (Atarax)
d. Promethazine (Phenergan)
e. Diphenhydramine (Benadryl)

 

 

ANS:  A, C, E

The coanalgesics prescribed for pruritus include naloxone, hydroxyzine, and diphenhydramine. Inapsine and promethazine are administered as antiemetics.

 

DIF:    Cognitive Level: Applying              REF:   p. 174            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A child receiving chemotherapy is experiencing mucositis. Which prescriptions should the nurse plan to administer for initial treatment? (Select all that apply.)
a. Scope mouth rinse
b. Listerine antiseptic mouth rinse
c. Carafate suspension (Sucralfate)
d. Nystatin oral suspension (Nystatin)
e. Lidocaine viscous (Lidocaine hydrochloride solution)

 

 

ANS:  C, D, E

Initial treatment of stomatitis includes single agents (sucralfate suspension, nystatin, and viscous lidocaine). Scope and Listerine are plaque and gingivitis control mouth rinses that would have a drying effect and are not used with mucositis.

 

DIF:    Cognitive Level: Applying              REF:   p. 188            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

COMPLETION

 

  1. A health care provider prescribes promethazine (Phenergan), 9 mg IV every 6 to 8 hours as needed for pruritus. The medication label states: “Promethazine 25 mg/1 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places.

________________

 

ANS:

0.36

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = mL per dose

Available

 

9 mg

———– ´ 1 mL = 0.36 mL

25 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes diphenhydramine (Benadryl), 1 mg/kg PO every 4 to 6 hours as needed for pruritus. The child weighs 10 kg. The medication label states: “Diphenhydramine 12.5 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

4

 

Follow the formula for dosage calculation.

Multiply 1 mg ´ 10 kg to get the dose = 10 mg

 

 

Desired

———– ´ Volume = mL per dose

Available

 

10 mg

———– ´ 5 mL = 4 mL

12.5 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes hydroxyzine (Atarax), 0.6 mg/kg PO every 4 to 6 hours as needed for pruritus. The medication label states: “Hydroxyzine 10 mg/5 mL.” The child weighs 20 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

6

 

Follow the formula for dosage calculation.

Multiply 0.6 mg ´ 20 kg to get the dose = 12 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

12 mg

———– ´ 5 mL = 6 mL

10 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A child receiving morphine sulfate (Morphine) is experiencing respiratory depression. A health care provider prescribes naloxone (Narcan), 0.5 mcg/kg IV in 2-minute increments until breathing improves. The medication label states: “Naloxone 400 mcg/1 mL.” The child weighs 40 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places.

________________

 

ANS:

0.05

 

Follow the formula for dosage calculation.

Multiply 0.5 mcg ´ 40 kg to get the dose = 20 mcg

 

Desired

———– ´ Volume = mL per dose

Available

 

20 mcg

———– ´ 1 mL = 0.05 mL

400 mcg

 

DIF:    Cognitive Level: Applying              REF:   p. 176

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes haloperidol (Haldol), 0.15 mg/kg IV every 4 to 6 hours as needed for confusion. The medication label states: “Haloperidol 2 mg/1 mL.” The child weighs 30 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer rounding to one decimal place.

________________

 

ANS:

2.3

 

Follow the formula for dosage calculation.

Multiply 0.15 mg ´ 30 kg to get the dose = 4.5 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

4.5 mg

———– ´ 1 mL = 2.25 mL = rounded to one decimal space = 2.3 mL

2 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 175

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes Kytril (granisetron), 10 mcg/kg IV every 4 to 6 hours as needed for nausea. The medication label states: “Kytril 100 mcg/1 mL.” The child weighs 15 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

_______________

 

ANS:

1.5

 

Follow the formula for dosage calculation.

Multiply 10 mcg ´ 15 kg to get the dose = 150 mcg

 

Desired

———– ´ Volume = mL per dose

Available

 

150 mcg

———– ´ 1 mL = 1.5 mL

100 mcg

 

DIF:    Cognitive Level: Applying              REF:   p. 174

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes OxyContin (oxycodone), 3 mg PO every 4 to 6 hours as needed for pain. The medication label states: “OxyContin 5 mg/1 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using one decimal place.

________________

 

ANS:

0.6

 

Follow the formula for dosage calculation.

Desired

———– ´ Volume = mL per dose

Available

 

3 mg

———– ´ 1 mL = 0.6 mL

5 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 172

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes acetaminophen (Tylenol) gtt, 10 mg/kg/dose PO every 4 to 6 hours as needed for pain. The infant weighs 8 kg. The medication label states: “Acetaminophen 80 mg/0.8 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

 

ANS:

0.8

 

Follow the formula for dosage calculation.

Multiply 10 mg ´ 8 kg to get the dose = 80 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

80 mg

———– ´ 0.8 mL = 0.8 mL

80 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes naproxen (Naprosyn), 7 mg/kg PO every 12 hours for pain. The child weighs 25 kg. The medication label states: “Naproxen 125 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

7

 

Follow the formula for dosage calculation.

Multiply 7 mg ´ 25 kg to get the dose = 175 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

175 mg

———– ´ 5 mL = 7 mL

125 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes choline magnesium trisalicylate (Trilisate), 15 mg/kg PO every 8 to 12 hours as needed for pain. The child weighs 10 kg. The medication label states: “Choline magnesium trisalicylate 500 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

 

ANS:

1.5

 

Follow the formula for dosage calculation.

Multiply 15 mg ´ 10 kg to get the dose = 150 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

150 mg

———– ´ 5 mL = 1.5 mL

500 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A health care provider prescribes ibuprofen (Motrin), 5 mg/kg PO every 6 to 8 hours as needed for pain. The child weighs 8 kg. The medication label states: “Ibuprofen 100 mg/5 mL.” The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

 

ANS:

2

 

Follow the formula for dosage calculation.

Multiply 5 mg ´ 8 kg to get the dose = 40 mg

 

Desired

———– ´ Volume = mL per dose

Available

 

40 mg

———– ´ 5 mL = 2 mL

100 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 171

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

MATCHING

 

Complementary and alternative medicine therapies are grouped into five classes. Match the complementary or alternative therapy to its classification.

a. Vitamins
b. Massage
c. Reiki
d. Hypnosis
e. Homeopathy

 

 

  1. Manipulative treatment

 

  1. Energy based

 

  1. Alternative medical system

 

  1. Mind–body technique

 

  1. Biologically based

 

  1. ANS:  B                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  C                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  E                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  D                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. ANS:  A                    DIF:    Cognitive Level: Understanding     REF:   p. 170

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

 

Chapter 19: Family-Centered Care of the Child with Chronic Illness or Disability

 

MULTIPLE CHOICE

 

  1. What is the major health concern of children in the United States?
a. Acute illness
b. Chronic illness
c. Congenital disabilities
d. Nervous system disorders

 

 

ANS:  B

An estimated 18% of children in the United States have a chronic illness or disability that warrants health care services beyond those usually required by children. Chronic illness has surpassed acute illness as the major health concern for children. Congenital disabilities exist from birth but may not be hereditary. These represent a portion of the number of children with chronic illnesses. Mental and nervous system disorders account for approximately 17% of chronic illnesses in children.

 

DIF:    Cognitive Level: Understanding     REF:   p. 761            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is a major premise of family-centered care?
a. The child is the focus of all interventions.
b. Nurses are the authorities in the child’s care.
c. Parents are the experts in caring for their child.
d. Decisions are made for the family to reduce stress.

 

 

ANS:  C

As parents become increasingly responsible for their children, they are the experts. It is essential that the health care team recognize the family’s expertise. In family-centered care, consistent attention is given to the effects of the child’s chronic illness on all family members, not just the child. Nurses are adjuncts in the child’s care. The nurse builds alliances with parents. Family members are involved in decision making about the child’s physical care.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What should the nurse determine to be the priority intervention for a family with an infant who has a disability?
a. Focus on the child’s disabilities to understand care needs.
b. Institute age-appropriate discipline and limit setting.
c. Enforce visiting hours to allow parents to have respite care.
d. Foster feelings of competency by helping parents learn the special care needs of the infant.

 

 

ANS:  D

It is important that the parents learn how to care for their infant so they feel competent. The nurse facilitates this by teaching special holding techniques, supporting breastfeeding, and encouraging frequent visiting and rooming in. The focus should be on the infant’s capabilities and positive features. Infants do not usually require discipline. As the child gets older, this is necessary, but it is not a priority intervention at this time. The nursing staff negotiates with the family about the need for respite care.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 763

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. The potential effects of chronic illness or disability on a child’s development vary at different ages. What developmental alteration is a threat to a toddler’s normal development?
a. Hindered mobility
b. Limited opportunities for socialization
c. Child’s sense of guilt that he or she caused the illness or disability
d. Limited opportunities for success in mastering toilet training

 

 

ANS:  A

Toddlers are acquiring a sense of autonomy, developing self-control, and forming symbolic representation through language acquisition. Mobility is the primary tool used by toddlers to experiment with maintaining control. Loss of mobility can create a sense of helplessness. Toddlers do not socialize. They are sensitive to changes in family routines. A sense of guilt is more likely to occur in a preschooler. Toilet training is not usually mastered until the end of the toddler period.

 

DIF:    Cognitive Level: Understanding     REF:   p. 768            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A feeling of guilt that the child “caused” the disability or illness is especially common in which age group?
a. Toddler
b. Preschooler
c. School-age child
d. Adolescent

 

 

ANS:  B

Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or disability or are being punished for wrongdoings. Toddlers are focused on establishing their autonomy. The illness fosters dependency. School-age children have limited opportunities for achievement and may not be able to understand limitations. Adolescents face the task of incorporating their disabilities into their changing self-concept.

 

DIF:    Cognitive Level: Understanding     REF:   p. 769

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What intervention is most appropriate for fostering the development of a school-age child with disabilities associated with cerebral palsy?
a. Provide sensory experiences.
b. Help develop abstract thinking.
c. Encourage socialization with peers.
d. Give choices to allow for feeling of control.

 

 

ANS:  C

Peer interaction is especially important in relation to cognitive development, social development, and maturation. Cognitive development is facilitated by interaction with peers, parents, and teachers. The identification with those outside the family helps the child fulfill the striving for independence. Sensory experiences are beneficial, especially for younger children. School-age children are too young for abstract thinking. Giving school-age children choices is always an important intervention. Providing structured choices allows for a feeling of control.

 

DIF:    Cognitive Level: Applying              REF:   p. 763

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. What should the nurse explain to his parents?
a. That he needs more discipline
b. That this is a normal part of adolescence
c. That he needs more socialization with peers
d. That this is how he is asking for more parental control

 

 

ANS:  B

Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence, during which young adults are establishing independence. If the parents increase the amount of discipline, he will most likely be more rebellious. More socialization with peers does not address the problem of risk-taking behavior.

 

DIF:    Cognitive Level: Applying              REF:   p. 767

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What nursing intervention is most appropriate in promoting normalization in a school-age child with a chronic illness?
a. Give the child as much control as possible.
b. Ask the child’s peer to make the child feel normal.
c. Convince the child that nothing is wrong with him or her.
d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings.

 

 

ANS:  A

The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child should be given as much control as possible. It is unrealistic for one individual to make the child feel normal. The child has a chronic illness, so it would be unacceptable to convince the child that nothing is wrong. The family rules should be similar for each of the children in a family. Resentment and hostility can arise if different standards are applied to each child.

 

DIF:    Cognitive Level: Applying              REF:   p. 769

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse should recognize that this is most likely an indication that the child is experiencing what emotional response?
a. Hopefulness
b. Chronic sorrow
c. Belief that procedures are a deserved punishment
d. Understanding that procedures indicate impending death

 

 

ANS:  C

The nurse should be particularly alert to a child who withdraws and passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment for being less worthy. A child who is hopeful is mobilized into goal-directed actions. This child would actively participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves over time. It is usually evident in the parents, not in the child. The seriously ill child would actively participate in care. Nursing interventions should be used to minimize the pain.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 774

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. The parents of a child born with disabilities ask the nurse for advice about discipline. The nurse’s response should be based on remembering that discipline is which?
a. Essential for the child
b. Not needed unless the child’s behavior becomes problematic
c. Best achieved with punishment for misbehavior
d. Too difficult to implement with a special needs child

 

 

ANS:  A

Discipline is essential for the child. It provides boundaries on which she can test out her behavior and teaches her socially acceptable behaviors. The nurse should teach the parents ways to manage the child’s behavior before it becomes problematic. Punishment is not effective in managing behavior.

 

DIF:    Cognitive Level: Applying              REF:   p. 777

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Parents ask for help for their other children to cope with the changes in the family resulting from the special needs of their sibling. What strategy does the nurse recommend?
a. Explain to the siblings that embarrassment is unhealthy.
b. Encourage the parents not to expect siblings to help them care for the child with special needs.
c. Provide information to the siblings about the child’s condition only as requested.
d. Invite the siblings to attend meetings to develop plans for the child with special needs.

 

 

ANS:  D

Siblings should be invited to attend meeting to be part of the care team for the child. They can learn about an individualized education plan and help design strategies that will work at home. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner without punishing the sibling. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities. Parents need to inform the siblings about the child’s condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is wrong with the child.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 780

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is assessing the coping behaviors of the parents of a child recently diagnosed with a chronic illness. What behavior should the nurse consider an “approach behavior” that results in movement toward adjustment?
a. Being unable to adjust to a progression of the disease or condition
b. Anticipating future problems and seeking guidance and answers
c. Looking for new cures without a perspective toward possible benefit
d. Failing to recognize the seriousness of the child’s condition despite physical evidence

 

 

ANS:  B

The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. These are positive actions in caring for their child. Being unable to adjust, looking for new cures, and failing to recognize the seriousness of the child’s condition are avoidance behaviors. The parents are moving away from adjustment or exhibiting maladaptation to the crisis of a child with chronic illness or disability.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 783

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What nursing intervention is especially helpful in assessing feelings of parental guilt when a disability or chronic illness is diagnosed?
a. Ask the parents if they feel guilty.
b. Observe for signs of overprotectiveness.
c. Talk about guilt only after the parents mention it.
d. Discuss the meaning of the parents’ religious and cultural background.

 

 

ANS:  D

Guilt may be associated with cultural or religious beliefs. Some parents are convinced that they are being punished for some previous misdeed. Others may see the disorder as a trial sent by God to test their religious beliefs. The nurse can help the parents explore their religious beliefs. On direct questioning, the parents may not be able to identify the feelings of guilt. It would be appropriate for the nurse to explore their adjustment responses. Overprotectiveness is a parental response during the adjustment phase. The parents fear letting the child achieve any new skill and avoid all discipline.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 784

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by what response?
a. Denial
b. Guilt and anger
c. Social reintegration
d. Acceptance of the child’s limitations

 

 

ANS:  B

For most families, the adjustment phase is accompanied by several responses, including guilt, self-accusation, bitterness, and anger. The initial diagnosis of a chronic illness or disability often is met with intense emotion and characterized by shock and denial. Social reintegration and acceptance of the child’s limitations are the culmination of the adjustment process.

 

DIF:    Cognitive Level: Understanding     REF:   p. 785            TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. What manifestation observed by the nurse is suggestive of parental overprotection?
a. Gives inconsistent discipline
b. Facilitates the child’s responsibility for self-care of illness
c. Persuades the child to take on activities of daily living even when not able
d. Encourages social and educational activities not appropriate to the child’s level of capability

 

 

ANS:  A

Parental overprotection is manifested when the parents fear letting the child achieve any new skill, avoid all discipline, and cater to every desire to prevent frustration. Overprotective parents do not allow the child to assume responsibility for self-care of the illness. The parents prefer to remain in the role of total caregiver. The parents do not encourage the child to participate in social and educational activities.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 785

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What finding by the nurse is most characteristic of chronic sorrow?
a. Lack of acceptance of child’s limitation
b. Lack of available support to prevent sorrow
c. Periods of intensified sorrow when experiencing anger and guilt
d. Periods of intensified sorrow at certain landmarks of the child’s development

 

 

ANS:  D

Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The sorrow is a response to the recognition of the child’s limitations. The family should be assessed in an ongoing manner to provide appropriate support as their needs change. The sorrow is not preventable. The chronic sorrow occurs during the reintegration and acknowledgment stage.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 785

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. A 5-year-old child will be starting kindergarten next month. She has cerebral palsy, and it has been determined that she needs to be in a special education classroom. Her parents are tearful when telling the nurse about this and state that they did not realize her disability was so severe. What is the best interpretation of this situation?
a. This is a sign the parents are in denial.
b. This is a normal anticipated time of parental stress.
c. The parents need to learn more about cerebral palsy.
d. The parents’ expectations are too high.

 

 

ANS:  B

Parenting a child with a chronic illness can be stressful. At certain anticipated times, parental stress increases. One of these identified times is when the child begins school. Nurses can help parents recognize and plan interventions to work through these stressful periods. The parents are not in denial; rather, they are responding to the child’s placement in school. The parents are not exhibiting signs of a remembering deficit; this is their first interaction with the school system with this child.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 778

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse notes that the parents of a critically ill child spend a large amount of time talking with the parents of another child who is also seriously ill. They talk with these parents more than with the nurses. How should the nurse interpret this situation?
a. Parent-to-parent support is valuable.
b. Dependence on other parents in crisis is unhealthy.
c. This is occurring because the nurses are unresponsive to the parents.
d. This has the potential to increase friction between the parents and nursing staff.

 

 

ANS:  A

Veteran parents share experiences that cannot be supplied by other support systems. They have known the stress related to diagnosis, have weathered the many transition times, and have a practical remembering of resources. The parents can be mutually supportive during times of crisis. Nursing staff cannot provide the type of support that is realized from other parents who are experiencing similar situations. Friction should not exist between the nursing staff and the family of the child who is critically ill.

 

DIF:    Cognitive Level: Applying              REF:   p. 787            TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is talking to the parent of a child with special needs. The parent has expressed worry about how to support the siblings at home. What suggestion is appropriate for the nurse to give to the parent?
a. “You should help the siblings see the similarities and differences between themselves and your child with special needs.”
b. “You should explain that your child with special needs should be included in all activities that the siblings participate in even if they are reluctant.”
c. “You should give the siblings many caregiving tasks for your child with special needs so the siblings feel involved.”
d. “You should intervene when there are differences between your child with special needs and the siblings.”

 

 

ANS:  A

Appropriate information to give to a parent who wants to support the siblings of a child with special needs includes helping the siblings see the differences and similarities between themselves and the child with special needs to promote an understanding environment. The parent should be encouraged to allow the siblings to participate in activities that do not always include the child with special needs, to limit caregiving responsibilities, and to allow the children to settle their own differences rather than step in all the time.

 

DIF:    Cognitive Level: Applying              REF:   p. 779            TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. What is the single most prevalent cause of disability in children and responsible for the recent increase in childhood disability?
a. Cancer
b. Asthma
c. Seizures
d. Heart disease

 

 

ANS:  B

Asthma is the single most prevalent cause of disability in children and has been largely responsible for much of the recent increase in childhood disability.

 

DIF:    Cognitive Level: Understanding     REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The parents of a child on a ventilator tell the nurse that their insurance company wants the child to be discharged. They explain that they do not want the child home “under any circumstances.” What principle should the nurse consider when working with this family?
a. Desire to have the child home is essential to effective home care.
b. Parents should not be expected to care for a technology-dependent child.
c. Having a technology-dependent child at home is better for both the child and the family.
d. Parents are not part of the decision-making process because of the costs of hospitalization.

 

 

ANS:  A

Home care requires the family to manage the child’s illness, including providing daily hands-on care, monitoring the child’s medical condition, and educating others to care for the child. The child’s home environment with the child’s family is perceived as the best place for the child to be cared for. If the family does not want to or is not able to assume these responsibilities, other arrangements need to be investigated. The family is an essential part of the decision-making process. Without family involvement and support, the technology-dependent child will not be well cared for at home.

 

DIF:    Cognitive Level: Understanding     REF:   p. 763            TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A child with a serious chronic illness will soon go home. The case manager requests that the family provide total care for the child for a couple of days while the child is still hospitalized. How should the request be viewed?
a. Improper because of legal issues
b. Supportive because families are usually eager to get involved
c. Unacceptable because the family will have to assume the care soon enough
d. Important because it can be beneficial to the transition from hospital to home

 

 

ANS:  D

This type of groundwork is essential for the family. Adequate family training and preparation will assist in the child’s transition home. The nursing staff in the hospital is responsible for the child’s care. The family will provide the care with assistance as needed. Although parents are eager to be involved, the purpose of this intervention is the development of family competency and confidence that they are capable. Arrangements for respite care are important for the family both during hospitalizations and while the child is at home.

 

DIF:    Cognitive Level: Understanding     REF:   p. 778            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. For case management to be most effective, who should be recognized as the most appropriate case manager?
a. Nurse
b. Panel of experts
c. Multidisciplinary team
d. Insurance company

 

 

ANS:  A

Nursing case managers are ideally suited to provide the care coordination necessary. Care coordination is most effective if a single person works with the family to accomplish the many tasks and responsibilities that are necessary. The family retains the role as primary decision maker. Most likely the insurance company will have a case manager focusing on the financial aspects of care. This does not include coordination of care to assist the family.

 

DIF:    Cognitive Level: Understanding     REF:   p. 782            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. An adolescent with long-term, complex health care needs will soon be discharged from the hospital. The nurse case manager has been assigned to the teen and family. The adolescent’s care involves physical therapy, occupational therapy, and speech therapy in addition to medical and nursing care. Who should be the decision maker in the adolescent’s care?
a. Adolescent
b. Nurse case manager
c. Adolescent and family
d. Multidisciplinary health care team

 

 

ANS:  C

The extent to which children are involved in their own care and decision making depends on many factors, including the child’s developmental age, level of interest, physical ability, and parental support. If the adolescent is developmentally age appropriate, then decision making should be the responsibility of child and family. Family needs to be involved because they will be caring for the adolescent in the home. Health care providers have necessary input into the care of the child, but ultimate decision making rests with the adolescent and family.

 

DIF:    Cognitive Level: Applying              REF:   p. 767            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse has been assigned as a home health nurse for a child who is technology dependent. The nurse recognizes that the family’s background differs widely from the nurse’s own. The nurse believes some of their lifestyle choices are less than ideal. What nursing intervention is most appropriate to institute?
a. Change the family.
b. Respect the differences.
c. Assess why the family is different.
d. Determine whether the family is dysfunctional.

 

 

ANS:  B

Respect for varied family structures and for racial, ethnic, cultural, and socioeconomic diversity among families is essential in home care. The nurse must assess and respect the family’s background and lifestyle choices. It is not appropriate to attempt to change the family. The nurse is a guest in the home and care of the child. The family and the values held by the cultural group prevail. The nurse may assess why the family is different to help the nurse and other health professionals understand the differences. It is not appropriate to determine whether the family is dysfunctional.

 

DIF:    Cognitive Level: Applying              REF:   p. 774

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. A child’s parents ask the nurse many questions about their child’s illness and its management. The nurse does not know enough to answer all the questions. What nursing action is most appropriate at this time?
a. Tell them, “I don’t know, but I will find out.”
b. Suggest that they ask the physician these questions.
c. Explain that the nurse cannot be expected to know everything.
d. Answer questions vaguely so they do not lose confidence in the nurse.

 

 

ANS:  A

Questions from parents should be answered in a straightforward manner. Stating “I don’t know” or “I’ll find out” is better than pretending to know or giving excuses. Suggesting that they ask the physician these questions is not supportive of the family. The nurse’s role is to assist the parents in obtaining accurate information about their child’s illness and its management. Although the nurse cannot be expected to know everything, it is an unprofessional attitude to state this. Nurses must provide accurate information to the extent possible. Vague answers are not helpful to the family.

 

DIF:    Cognitive Level: Applying              REF:   p. 775

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse outlines short- and long-term goals for a 10-year-old child with many complex health problems. Who should agree on these goals?
a. Family and nurse
b. Child, family, and nurse
c. All professionals involved
d. Child, family, and all professionals involved

 

 

ANS:  D

In the home, the family is a partner in each step of the nursing process. The family priorities should guide the planning process. Both short- and long-term goals should be outlined and agreed on by the child, family, and professionals involved. Elimination of any one of these groups can potentially create a care plan that does not meet the needs of the child and family.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 777            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. When communicating with other professionals about a child with a chronic illness, what is important for nurses to do?
a. Ask others what they want to know.
b. Share everything known about the family.
c. Restrict communication to clinically relevant information.
d. Recognize that confidentiality is not possible in home care.

 

 

ANS:  C

The nurse needs to share, through both oral and written communication, clinically relevant information with other involved health professionals. Asking others what they want to know and sharing everything known about the family are inappropriate measures. Patients have a right to confidentiality. Confidentiality permits the disclosure of information to other health professionals on a need-to-know basis.

 

DIF:    Cognitive Level: Applying              REF:   p. 761

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care

 

  1. The nurse has been visiting an adolescent with recently acquired tetraplegia. The teen’s mother tells the nurse, “I’m sick of providing all the care while my husband does whatever he wants to, whenever he wants to do it.” What reaction should be the nurse’s initial response?
a. Refer the mother for counseling.
b. Listen and reflect the mother’s feelings.
c. Ask the father in private why he does not help.
d. Suggest ways the mother can get her husband to help.

 

 

ANS:  B

It is appropriate for the nurse to reflect with the mother about her feelings, exploring solutions such as an additional home health aide to help care for the child and provide respite for the mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping enough. This judgment is beyond the role of the nurse and can undermine the family relationship. Counseling, if indicated, would be necessary for both parents. A support group for caregivers may be indicated. The nurse should not ask the father in private why he does not help or suggest way the mother can get her husband to help. These interventions are based on the mother’s perceptions; the father may have a full-time job and other commitments. The parents may need an unbiased third person to help them through the negotiation of their new parenting responsibilities.

 

DIF:    Cognitive Level: Applying              REF:   p. 763

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is planning care for a 3-year-old boy who has Down syndrome and is on continuous oxygen. He recently began walking around furniture. He is spoon fed by his parents and eats some finger foods. What goal is the most appropriate to promote normal development?
a. Encourage mobility.
b. Encourage assistance in self-care.
c. Promote oral-motor development.
d. Provide opportunities for socialization.

 

 

ANS:  A

A major principle for developmental support in children with complex medical issues is that it should be flexible and tailored to the individual child’s abilities, interests, and needs. This child is exhibiting readiness for ambulation. It is an appropriate time to provide activities that encourage mobility, for example, longer oxygen tubing. Parents should provide decreasing amounts of assistance with self-care as he is able to develop these skills. The boy is receiving oral foods and is eating finger foods. He has acquired this skill. Mobility is a new developmental task. Opportunities for socialization should be ongoing.

 

DIF:    Cognitive Level: Applying              REF:   p. 763            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What behavior seen in children should be addressed by the nurse who is providing care to a child with a chronic illness?
a. An infant who is uncooperative
b. A toddler who expresses loneliness
c. A preschooler who refuses to participate in self-care
d. An adolescent who is showing independence

 

 

ANS:  C

Preschoolers thrive on being independent and are in the phase of gaining autonomy, so they want to perform as many self-care tasks as possible. If a preschooler is refusing to participate in self-care activities, then the home health nurse should address this. Infants are uncooperative by nature, and toddlers do not understand the concept of loneliness, so these are not observations that would need to be addressed. Adolescents are always striving for independence, so this is a normal observation; if the adolescent were becoming more dependent on family, it might require intervention.

 

DIF:    Cognitive Level: Applying              REF:   p. 768

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse asks the mother of a child with a chronic illness many questions as part of the assessment. The mother answers several questions, then stops and says, “I don’t know why you ask me all this. Who gets to know this information?” The nurse should respond in what manner?
a. Determine why the mother is so suspicious.
b. Determine what the mother does not want to tell.
c. Explain who will have access to the information.
d. Explain that everything is confidential and that no one else will know what is said.

 

 

ANS:  C

Communication with the family should not be invasive. The nurse needs to explain the importance of collecting the information, its applicability to the child’s care, and who will have access to the information. The mother is not being suspicious and is not necessarily withholding important information. She has a right to understand how the information she provides will be used. The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals.

 

DIF:    Cognitive Level: Applying              REF:   p. 773

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. One of the supervisors for a home health agency asks the nurse to give a family of a child with a chronic illness a survey evaluating the nurses and other service providers. How should the nurse recognize this request?
a. Appropriate to improve quality of care
b. Improper because it is an invasion of privacy
c. Inappropriate unless nurses and other providers agree to participate
d. Not acceptable because the family lacks remembering necessary to evaluate professionals

 

 

ANS:  A

Quality assessment and improvement activities are essential for virtually all organizations. Family involvement in evaluating a home care plan can occur on several levels. The nurse can ask the family open-ended questions at regular intervals to assess their opinion of the effectiveness of care. Families should also be given an opportunity to evaluate the individual home care nurses, the home care agency, and other service providers periodically. Evaluation of the provision of care to the patient and family requires evaluation of the care provider, that is, the nurse. Quality-monitoring activities are required by virtually all health care agencies. During the evaluation process, the family is asked to provide their perceptions of care.

 

DIF:    Cognitive Level: Applying              REF:   p. 763

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. The nurse is planning to use an interpreter with a non–English-speaking family. What should the nurse plan with regard to the use of an interpreter? (Select all that apply.)
a. Use a family member.
b. The nurse should speak slowly.
c. Use an interpreter familiar with the family’s culture.
d. The nurse should speak only a few sentences at a time.
e. The nurse should speak to the interpreter during interactions.

 

 

ANS:  B, C, D

When parents who do not speak English are informed of their child’s chronic illness, interpreters familiar with both their culture and language should be used. The nurse should speak slowly and only use a few sentences at a time. Children, family members, and friends of the family should not be used as translators because their presence may prevent parents from openly discussing the issues. The nurse should speak to the family, not the interpreter.

 

DIF:    Cognitive Level: Applying              REF:   p. 765

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching coping strategies to parents of a child with a chronic illness. What coping strategies should the nurse include? (Select all that apply.)
a. Listen to the child.
b. Accept the child’s illness.
c. Establish a support system.
d. Learn to care for the child’s illness one day at a time.
e. Do not share information with the child about the illness.

 

 

ANS:  A, B, C, D

Coping strategies for parents caring for a child with a chronic illness include listening to the child, accepting the child’s illness, establishing a support system, and learning to care for the child’s illness one day at a time. Information should be shared with the child about the illness.

 

DIF:    Cognitive Level: Applying              REF:   p. 782

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What are supportive interventions that can assist an infant with a chronic illness to meet developmental milestones? (Select all that apply.)
a. Encourage consistent caregivers.
b. Encourage periodic respite from demands of care.
c. Encourage one family member to be the primary caretaker.
d. Encourage parental “rooming in” during hospitalization.
e. Withhold age-appropriate developmental tasks until the child is older.

 

 

ANS:  A, B, D

To develop trust, consistent caretakers and parents “rooming in” should be encouraged. To develop a sense of separateness from parents, periodic respites from caregiving should be encouraged. All members of the family, not one primary caretaker, should be encouraged to participate in care. Age-appropriate developmental tasks should be encouraged, not withheld until an older age.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 766

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing coping behaviors of a family with a child with a chronic illness. What indicates approach coping behaviors? (Select all that apply.)
a. Plans realistically for the future
b. Verbalizes possible loss of the child
c. Uses magical thinking and fantasy
d. Realistically perceives the child’s condition
e. Does not share the burden of the disorder with others

 

 

ANS:  A, B, D

Approach coping behaviors include planning realistically for the future, verbalizing possible loss of a child, and realistically perceiving the child’s behavior. Using magical thinking and fantasy is an avoidance behavior. The family should share the burden of the disorder with others as an approach behavior.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 783

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What are supportive interventions that can assist a toddler with a chronic illness to meet developmental milestones? (Select all that apply.)
a. Give choices.
b. Provide sensory experiences.
c. Avoid discipline and limit setting.
d. Discourage negative and ritualistic behaviors.
e. Encourage independence in as many areas as possible.

 

 

ANS:  A, B, E

To encourage autonomy, choices should be given and independence encouraged in as many areas as possible. Sensory experiences should be encouraged to help the toddler to learn through sensorimotor experiences. Age-appropriate discipline and limit setting should be initiated. Negative and ritualistic behaviors are normal and should be allowed.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 766

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing coping behaviors of a family with a child with a chronic illness. What indicates avoidance coping behaviors? (Select all that apply.)
a. Refuses to agree to treatment
b. Avoids staff, family members, or child
c. Is unable to discuss possible loss of the child
d. Recognizes own growth through a passage of time
e. Makes no change in lifestyle to meet the needs of other family members

 

 

ANS:  A, B, C, E

Avoidance coping behaviors include refusing to agree to treatment; avoiding staff, family members, or child; unable to discuss possible loss of the child; and making no change in lifestyle to meet the needs of other family members. Recognizing one’s own growth through a passage of time is an approach behavior.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 783

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What are supportive interventions that can assist a preschooler with a chronic illness to meet developmental milestones? (Select all that apply.)
a. Encourage socialization.
b. Encourage mastery of self-help skills.
c. Provide devices that make tasks easier.
d. Clarify that the cause of the child’s illness is not his or her fault.
e. Discuss planning for the future and how the condition can affect choices.

 

 

ANS:  A, B, C, D

To encourage initiative, mastery of self-help skills should be encouraged, and devices should be provided that make tasks easier. To develop peer relationships, socialization should be encouraged. To develop body image, the fact that the cause of the child’s illness is not the fault of the child should be emphasized. Discussing planning for the future and how the condition can affect choices is appropriate for an adolescent.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 766

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The parent of a child with a chronic illness tells the nurse, “I feel so hopeless in this situation.” The nurse should take which actions to foster hopefulness for the family? (Select all that apply.)
a. Avoid topics that are lighthearted.
b. Convey a personal interest in the child.
c. Be honest when reporting on the child’s condition.
d. Do not initiate any playful interaction with the child.
e. Demonstrate competence and gentleness when delivering care.

 

 

ANS:  B, C, E

To foster hopefulness, the nurse should convey a personal interest in the child, be honest when reporting on a child’s condition, and demonstrate competence and gentleness when delivering care. The nurse should introduce conversations on neutral, non–disease-related, or less sensitive topics (discuss the child’s favorite sports, tell stories). The nurse should be lighthearted and initiate or respond to teasing or other playful interactions with the child.

 

DIF:    Cognitive Level: Applying              REF:   p. 767

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What are supportive interventions that can assist a school-age child with a chronic illness to meet developmental milestones? (Select all that apply.)
a. Encourage socialization.
b. Discourage sports activities.
c. Encourage school attendance.
d. Provide instructions on assertiveness.
e. Educate teachers and classmates about the child’s condition.

 

 

ANS:  A, C, E

To develop a sense of accomplishment, school attendance should be encouraged, and teachers and classmates should be educated about the child’s condition. To form peer relationships, socialization should be encouraged. Sports activities should be encouraged (e.g., Special Olympics), not discouraged. Providing instructions on assertiveness is appropriate for adolescence.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 766

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What are supportive interventions that can assist an adolescent with a chronic illness to meet developmental milestones? (Select all that apply.)
a. Encourage activities appropriate for age.
b. Avoid discussing planning for the future.
c. Provide instruction on interpersonal and coping skills.
d. Emphasize good appearance and wearing of stylish clothes.
e. Understand that the adolescent will not have the same sexual needs.

 

 

ANS:  A, C, D

To achieve independence from family, instruction on interpersonal and coping skills should be provided. To promote heterosexual relationships, activities appropriate for age should be encouraged, and a good appearance and wearing of stylish clothes should be emphasized. Plans for the future should be discussed, and the adolescent will have the same sexual needs as adolescents without a chronic illness.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 767

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

MATCHING

 

Match the concepts related to children with special health care needs to their definitions.

a. Chronic illness
b. Congenital disability
c. Developmental disability
d. Impairment
e. Special needs

 

 

  1. A loss or abnormality of structure or function

 

  1. Any mental or physical disability that is manifested before the age of 18 years

 

  1. A long-lasting or recurrent condition that interferes with daily functioning that persists for more than 3 months

 

  1. A disability that has existed since birth but may not be hereditary

 

  1. A condition requiring assistance for disabilities that may be medical, mental, or psychological

 

  1. ANS:  C                    DIF:    Cognitive Level: Understanding     REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  D                    DIF:    Cognitive Level: Understanding     REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  B                    DIF:    Cognitive Level: Understanding     REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  A                    DIF:    Cognitive Level: Understanding     REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. ANS:  E                    DIF:    Cognitive Level: Understanding     REF:   p. 762

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

Chapter 27: Overview of Oxygen and Carbon Dioxide Exchange

 

MULTIPLE CHOICE

 

  1. What respiratory condition or disease results in both increased compliance and increased resistance?
a. Asthma
b. Atelectasis
c. Surfactant deficiency
d. Bronchopulmonary dysplasia

 

 

ANS:  A

Compliance is a measure of the relative ease with which the chest wall expands. Resistance is determined primarily by airway size. Asthma results in increased compliance and increased resistance, both of which increase the work of breathing. Atelectasis and surfactant deficiency both decrease compliance but do not affect resistance. Bronchopulmonary dysplasia increases resistance but does not affect compliance.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1126

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. How much oxygen is contained in ambient air (room air)?
a. 15%
b. 21%
c. 30%
d. 42%

 

 

ANS:  B

Room air is composed of 21% oxygen, trace amounts of carbon dioxide, and 79% nitrogen.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1127

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. During a respiratory assessment, the nurse notes a sinking in of soft tissues relative to the cartilaginous and bony thorax. What is the term for this finding?
a. Grunting
b. Tachypnea
c. Retractions
d. Nasal flaring

 

 

ANS:  C

Retractions are defined as the sinking of soft tissue relative to the cartilaginous or bony thorax. Retractions can be extreme in severe airway obstruction as the work of breathing increases. Grunting can be a sign of pain in older children with respiratory issues. It serves to increase the end-respiratory pressure, which prolongs the period of oxygen and carbon dioxide exchange across the membrane. Tachypnea is an increase in the respiratory rate above the child’s baseline. Nasal flaring, the enlargement of the nostrils, helps reduce nasal resistance and maintains airway patency.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1133

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What test measures the amount of air inhaled and exhaled during any respiratory cycle?
a. Tidal volume
b. Vital capacity
c. Dynamic compliance
d. Pulmonary resistance

 

 

ANS:  A

Tidal volume is defined as the amount of air inhaled and exhaled during any respiratory cycle. When it is multiplied by the respiratory rate, the minute volume is obtained. Forced vital capacity is the maximum amount of air that can be expired after maximum inspiration. It is used to monitor individuals with obstructive airway disease. Dynamic compliance is the relationship between the change in volume and pressure difference. Pulmonary resistance measures the changes in pressure with changes in flow on inspiration and expiration.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1135

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What is the best explanation for using pulse oximetry on young children to determine oxygen saturation?
a. Pulse oximetry is noninvasive.
b. Pulse oximetry is better than capnography.
c. Pulse oximetry is more accurate than arterial blood gases.
d. Pulse oximetry provides intermittent measurements of oxygen.

 

 

ANS:  A

Pulse oximetry is a noninvasive measure of oxygen saturation of hemoglobin. Capnography measures carbon dioxide inhalation and exhalation. It does not provide information about oxygen saturation. Arterial blood gases provide additional clinical information, including pH, PCO2, bicarbonate, base excess, and PO2. An arterial puncture is required, which can be painful, and continuous monitoring cannot be done without an arterial line. Pulse oximetry can be either intermittent or continuous.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1138

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. It is important to make certain that sensory connectors and oximeters are compatible because incompatible wiring can cause which condition?
a. Hyperthermia
b. Electrocution
c. Pressure necrosis
d. Burns under sensors

 

 

ANS:  D

Incompatible wiring can generate considerable heat at the tip of the sensor, resulting in partial- and full-thickness burns. Heat may be generated at the site of the sensor, but it will not result in generalized hyperthermia. Electrocution is not a possibility with oximeters. Pressure necrosis can occur from improperly applied sensors but not from incompatible wiring.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1139          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. What test should the nurse do as a precautionary measure before doing an arterial puncture to obtain an arterial blood sample?
a. Allen test
b. Smith test
c. Venipuncture
d. Cold compress

 

 

ANS:  A

The Allen test determines the adequacy of collateral circulation in the extremity distal to the proposed puncture site. If the child does not have satisfactory circulation when the proposed artery is occluded, that extremity is not used. The Smith test, venipuncture, and a cold compress are not done before arterial blood gas sampling.

 

DIF:    Cognitive Level: Applying              REF:   p. 1136          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. Arterial blood gases have just been drawn on a child. What should the nurse do next?
a. Take the sample to the laboratory immediately.
b. Pack the sample in ice and take it to the laboratory immediately.
c. Place the sample in a brown bag until it can be taken to laboratory.
d. Refrigerate the sample until it can be taken to the laboratory.

 

 

ANS:  B

Arterial blood gases require careful handling for accurate results. Immediately after obtaining the specimen, the nurse packs it in ice to reduce cellular metabolism and takes it to the laboratory.

 

DIF:    Cognitive Level: Applying              REF:   p. 1140

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The continuous administration of mist, or aerosolized water, for the treatment of inflammatory conditions of the airways is a common practice that functions in which manner?
a. Has no proven benefit
b. Decreases the viscosity of mucus
c. Decreases bronchoconstriction
d. Reduces the inflammation of the lower airways

 

 

ANS:  A

Aerosol therapy or mist therapy with water is not a treatment of choice for inflammatory airway conditions. Some questionable benefit may occur in mild viral croup. The parent and child may experience a reduction in anxiety in a cool, humid environment. Upper airway secretions may be moistened; however, inhaled mist does not affect the viscosity of mucus. Humidity may worsen bronchospasm. Aerosolized medications are able to reduce inflammation of the lower airways, but water does not have this effect.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1142          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. When is bronchial (postural) drainage generally performed?
a. Before meals and at bedtime
b. Right before all aerosol therapy
c. Immediately on arising and at bedtime
d. Thirty minutes after meals and at bedtime

 

 

ANS:  A

The therapy should be done at bedtime and before meals or 1 to 1 1/2 hours after meals to avoid stomach upset. Postural drainage is most effective when it is performed after other respiratory therapy interventions, including bronchodilator and nebulizer treatments. Immediately on arising and at bedtime are appropriate times, but postural drainage is usually carried out at least three times each day. Thirty minutes after meals may induce vomiting.

 

DIF:    Cognitive Level: Applying              REF:   p. 1143          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. What nursing consideration is most important in the care of a child on a mechanical ventilator?
a. Humidification is not necessary.
b. Respiratory assessment is done by the ventilator.
c. Positioning the child for comfort and optimum ventilation is necessary.
d. Support and reassurance are not as important because the child is unconscious.

 

 

ANS:  C

The ventilator will do the work of breathing, but the nurse must position the child with attention to achieving optimum gas exchange. The reason for mechanical ventilation and the child’s comfort are part of the assessment. Mechanical ventilation is usually achieved by intubation or tracheostomy. These routes bypass the humidification that occurs in the upper airway. The ventilator provides some information about the work of breathing, but patient assessment must be done by the nurse. Support and reassurance are always important for both the child and family. Opioids and anxiolytics are often used to decrease the child’s anxiety. Careful assessment is indicated.

 

DIF:    Cognitive Level: Applying              REF:   p. 1149          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. What intervention is necessary when weaning a child from the ventilator?
a. Light sedation before scheduled extubation
b. No suctioning before scheduled extubation
c. Cool mist begun immediately after extubation
d. Vigorous chest physiotherapy and suctioning performed immediately after extubation

 

 

ANS:  C

A cool mist or noninvasive oxygen therapy is initiated immediately after extubation. Steroids may be administered to minimize any laryngeal edema. Analgesics may be given, but sedation is not usually indicated. The child is suctioned just before extubation to ensure that the airway is clear. Chest physiotherapy and suctioning are performed before extubation.

 

DIF:    Cognitive Level: Applying              REF:   p. 1150

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse must suction a 6-month-old infant with a tracheostomy. What intervention should be included?
a. Encourage the child to cough to raise the secretions before suctioning.
b. Perform each pass of the suction catheter for no longer than 5 seconds.
c. Allow the child to rest after every five times the suction catheter is passed.
d. Select a catheter with a diameter three quarters of the diameter of the tracheostomy tube.

 

 

ANS:  B

Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be occluded for too long. An infant would be unable to cooperate with instructions to cough up secretions. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear. The catheter should have a diameter one half the size of the tracheostomy tube. If it is too large, it might block the child’s airway.

 

DIF:    Cognitive Level: Applying              REF:   p. 1152

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A 3-year-old child with a tracheostomy will soon be discharged. What recommendation should the nurse share with the family?
a. Tub baths cannot be given.
b. The child cannot be allowed to play outdoors.
c. Avoid exposure to noxious fumes such as paint or varnish.
d. Cover the tracheostomy with a plastic bib when exposed to cold air.

 

 

ANS:  C

The child with a tracheostomy should not be exposed to noxious fumes such as paint, varnish, or hair spray or to substances such as talc. The parent and child must be cautioned about safety measures around bodies of water. Baths can be taken, but parents must observe the necessary safety precautions. The child may play outdoors with a scarf or other protection that allows air through.

 

DIF:    Cognitive Level: Applying              REF:   p. 1155

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is planning home care for a 2-year-old child with a tracheostomy. What recommendation should be included?
a. Sterile technique is essential in home care of the tracheostomy.
b. Parents are able to change the tracheostomy tube when needed.
c. Play activities must be sedentary such as listening to music and working on puzzles.
d. The child must wear a plastic bib when eating or drinking to prevent aspiration into the stoma.

 

 

ANS:  B

A plugged, clogged, or obstructed tracheostomy tube is a life-threatening circumstance. Parents are taught the signs and symptoms, how to suction, and how to change the tube. Clean technique and thorough hand washing are sufficient for suctioning, cleaning the tracheostomy site, and changing the tracheostomy tube. The child who is physically able can engage in activities appropriate to age. Young children who may spill food near the stoma should wear a fabric bib without a plastic lining or other device to prevent dribbled food and crumbs from being aspirated.

 

DIF:    Cognitive Level: Applying              REF:   p. 1155

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity

 

  1. Respiratory failure can result from many causes. What condition is a specific primary cause of inefficient gas transfer?
a. Anemia
b. Pneumothorax
c. Cystic fibrosis
d. Laryngospasm

 

 

ANS:  A

Respiratory failure is defined as the inability of the respiratory system to maintain adequate oxygenation of the blood. In primary inefficient gas transfer, there is insufficient alveolar ventilation. Anemia, which is characterized by low hemoglobin levels, results in an inability to adequately oxygenate the blood. Pneumothorax and cystic fibrosis are examples of restrictive lung disease. Laryngospasm is an example of obstructive lung disease.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1127

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a child with a tracheostomy. What clinical manifestation should the nurse recognize as an early sign of impending respiratory distress or failure?
a. Cyanosis
b. Restlessness
c. Audible stridor
d. Crowing respirations

 

 

ANS:  B

Signs of hypoxemia are initially subtle. Cardinal signs of impending respiratory failure include restlessness, tachypnea, tachycardia, and diaphoresis. Cyanosis is a sign of severe hypoxia. Stridor and crowing respirations are indicative of inflammation. Sternal retractions are an early but less obvious sign.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1157

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. Cardiopulmonary resuscitation is begun on a toddler. What pulse is usually palpated because it is the most central and accessible?
a. Radial
b. Carotid
c. Femoral
d. Brachial

 

 

ANS:  B

In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse. The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants younger than 1 year of age.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1128

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What medication is considered to be the most useful in treating cardiac arrest?
a. Bretylium tosylate (Bretylium)
b. Xylocaine (lidocaine)
c. Adrenaline (epinephrine)
d. Naloxone (Narcan)

 

 

ANS:  C

Epinephrine is considered one of the most useful drugs in treating cardiac arrest. As an adrenergic agent, it acts on both a- and b-receptors in the heart. Epinephrine is rapidly cleared from the bloodstream. Bretylium is no longer used in pediatric cardiac arrest management. Lidocaine is used for ventricular arrhythmias only. Naloxone is useful only to reverse effects of opioids.

 

DIF:    Cognitive Level: Applying              REF:   p. 1150

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. Effective cardiopulmonary resuscitation (CPR) on a 5-year-old child should include what technique?
a. Provide one breath to every five chest compressions.
b. Provide two breaths to every 30 chest compressions.
c. Reassess the child every 10 minutes while CPR continues.
d. Evaluate the child after 50 cycles of compression and ventilation.

 

 

ANS:  B

Two breaths to 15 compressions is the standard for infants and children when two rescuers are present. One breath to every five chest compressions is not the appropriate ratio for CPR in this age group. Reassessment of the child should take place after 20 cycles or 1 minute.

 

DIF:    Cognitive Level: Applying              REF:   p. 1140

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A series of subdiaphragmatic abdominal thrusts (the Heimlich maneuver) is recommended for airway obstruction in children older than which age?
a. 1 year
b. 4 years
c. 8 years
d. 12 years

 

 

ANS:  A

A series of subdiaphragmatic abdominal thrusts (the Heimlich maneuver) is recommended for airway obstruction in children older than 1 year. For children younger than 1 year, back blows and chest thrusts are administered.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1145

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The mother of a toddler yells to the nurse, “Help! He is choking to death on his food!” The nurse determines that lifesaving measures are necessary based on which finding?
a. Gagging
b. Coughing
c. Pulse over 100 beats/min
d. Inability to speak

 

 

ANS:  D

The inability to speak is indicative of a foreign body airway obstruction of the larynx. Abdominal thrusts are needed for treatment of the choking child. Gagging, not obstruction, indicates irritation at the back of the throat. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons.

 

DIF:    Cognitive Level: Applying              REF:   p. 1134

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a 4-year-old child who is receiving 2 L of oxygen per nasal cannula. What disadvantage should the nurse consider when planning care for the child?
a. The child may need to have high humidity administered with the oxygen.
b. The child may not be able to eat and drink comfortably.
c. A nasal cannula may cause an accumulation of moisture on the face.
d. A nasal cannula may cause abdominal distention.

 

 

ANS:  D

All oxygen delivery systems have advantages and disadvantages. One disadvantage of a nasal cannula is possible abdominal distention and discomfort, which could lead to vomiting. The advantages include that the child is able to eat and drink more comfortably, there is no need for a high humidity environment, and there is no accumulation of moisture causing skin irritation.

 

DIF:    Cognitive Level: Applying              REF:   p. 1141          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A 5-month-old infant is in respiratory distress. What should the nurse expect to find?
a. Nasal flaring
b. Bradycardia
c. Abdominal breathing
d. Capillary refill of 2 seconds

 

 

ANS:  A

Nasal flaring is a sign of respiratory distress and a significant finding in an infant. The enlargement of the nostrils helps reduce nasal resistance and maintains airway patency. Nasal flaring may be intermittent or continuous and should be described as minimum or marked. The infant would have tachycardia, not bradycardia, in respiratory distress. Abdominal breathing and a capillary refill are normal findings in an infant.

 

DIF:    Cognitive Level: Applying              REF:   p. 1157          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A child is in uncompensated respiratory acidosis. What should the nurse expect the arterial blood gas to be?
a. O2, 95; CO2, 45; pH, 7.40
b. O2, 88; CO2, 55; pH, 7.30
c. O2, 88; CO2, 35; pH, 7.28
d. O2, 92; CO2, 54; pH, 7.35

 

 

ANS:  B

Respiratory acidosis results from diminished or inadequate pulmonary ventilation that causes an elevation in plasma Pco2 and thus an increased concentration of dissolved carbonic acid, which leads to elevated carbonic acid and hydrogen ion concentration. This tends to lower the pH. CO2 of 55 is elevated (normal CO2 is 35–45), and a pH of 7.30 is low (normal pH is 7.35–7.45).

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1130          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A child is in uncompensated respiratory alkalosis. What should the nurse expect the arterial blood gas to be?
a. CO2, 30; pH, 7.50
b. CO2, 55; pH, 7.30
c. CO2, 35; pH, 7.28
d. CO2, 54; pH, 7.35

 

 

ANS:  A

Laboratory findings in respiratory alkalosis include reduced PCO2 (<35?9?mm?9?Hg) and elevated plasma pH (>7.45).

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1131          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A child is in uncompensated metabolic alkalosis. What should the nurse expect the arterial blood gas to be?
a. HCO3, 24; pH, 7.35
b. HCO3, 28; pH, 7.50
c. HCO3, 20; pH, –7.30
d. HCO3, 26; pH, 7.40

 

 

ANS:  B

Metabolic alkalosis results in an elevated plasma pH (normal pH is 7.35–7.45) that occurs when there is an excess of bicarbonate (normal HCO3 is 22–26).

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1132          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A child is in uncompensated metabolic acidosis. What should the nurse expect the arterial blood gas to be?
a. HCO3, 24; pH, 7.35
b. HCO3,  28; pH, 7.50
c. HCO3,  20; pH, 7.30
d. HCO3,  26; pH,  7.40

 

 

ANS:  C

Laboratory findings of uncompensated metabolic acidosis include lowered plasma pH (<7.35) and diminished plasma bicarbonate concentration (normal HCO3 is 22–26).

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1132          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A nurse is calculating the correlation of Pao2 with Sao2 according to the oxyhemoglobin dissociation curve. What parameter should indicate that the Pao2 is less than 50 to 60 mm Hg?
a. Coarse lung sounds
b. Temperature of 100° F
c. Respiratory rate of 58
d. Pulse oximetry reading of 90% or less

 

 

ANS:  D

The Pao2 can be correlated with the Sao2 by means of the oxyhemoglobin dissociation curve, although changes in Pao2 do not cause identical (linear) changes in Sao2. The curve represents the relationship between Pao2 (measured in the blood) and Sao2 (measured by the pulse oximeter). When the Pao2 is 60?9?mm?9?Hg, the Sao2 is 90%. The oxyhemoglobin dissociation curve does not correlate with lung sounds, temperature, or respiratory rate.

 

DIF:    Cognitive Level: Applying              REF:   p. 1139

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is reviewing factors that affect lung development. What factor delays surfactant production and maturation of alveolar cells?
a. Thyroxine
b. Prolactin
c. Glucocorticosteroids
d. Excess of endogenous insulin

 

 

ANS:  D

An excess of endogenous insulin can delay surfactant production and delays maturation of alveolar cells. Glucocorticosteroids, thyroxine, and prolactin enhance lung development.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1125

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a child in respiratory distress. What is an early but less obvious sign of respiratory failure?
a. Stupor
b. Headache
c. Bradycardia
d. Somnolence

 

 

ANS:  B

An early but less obvious sign of respiratory failure is a headache. Stupor, bradycardia, and somnolence are signs of more severe hypoxia.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1142

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for a child on oxygen being delivered by a nasal cannula. What is the advantage of delivering oxygen in this manner?
a. It can deliver mist if desired.
b. It is less likely to cause abdominal distention.
c. The child is able to eat and talk while getting oxygen.
d. This method can deliver a higher concentration of oxygen.

 

 

ANS:  C

An advantage of delivering oxygen by nasal cannula is that the child is able to eat and talk while getting oxygen. This method cannot deliver mist or higher concentrations of oxygen. A disadvantage of this method is that it may cause abdominal distention.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1141          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is evaluating arterial blood gas results. What condition can cause an increase in PCO2?
a. Hypoxia
b. Hyperventilation
c. Pulmonary embolism
d. Obstructive lung disease

 

 

ANS:  D

Obstructive lung disease causes an increase in PCO2. Hypoxia, hyperventilation, and pulmonary embolism cause a decrease in PCO2.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1138          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is evaluating arterial blood gas results. What condition can cause an increase in HCO3?
a. Renal failure
b. Lactic acidosis
c. Diabetic ketoacidosis
d. Fluid loss from upper gastrointestinal tract

 

 

ANS:  D

Fluid loss from an upper gastrointestinal tract causes an increase in HCO3. Renal failure, lactic acidosis, and diabetic ketoacidosis cause a decrease in HCO3.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1138          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is analyzing an arterial blood gas of pH, 7.30; PCO2, 50; and HCO3, 29. What result should the nurse document for this blood gas?
a. Fully compensated respiratory acidosis
b. Partially compensated respiratory acidosis
c. Fully compensated metabolic acidosis
d. Partially compensated metabolic acidosis

 

 

ANS:  B

When the fundamental acid–base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid–base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In respiratory acidosis, the pH is low (?6?7.35), and the PCO2 is high (?7?45). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the HCO3 is high (?7?26), indicating an attempt at compensation.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1129

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is analyzing an arterial blood gas of pH, 7.50; PCO2, 50; and HCO3, 29. What result should the nurse document for this blood gas?
a. Fully compensated metabolic alkalosis
b. Partially compensated metabolic alkalosis
c. Fully compensated respiratory alkalosis
d. Partially compensated respiratory alkalosis

 

 

ANS:  B

When the fundamental acid–base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid–base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In metabolic alkalosis, the pH is high (?7?7.45), and the HCO3 is high (?7?26). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the PCO2 is high (?7?45), indicating an attempt at compensation.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1129

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is analyzing an arterial blood gas of pH, 7.29; PCO2, 30; and HCO3, 20. What result should the nurse document for this blood gas?
a. Fully compensated respiratory acidosis
b. Partially compensated respiratory acidosis
c. Fully compensated metabolic acidosis
d. Partially compensated metabolic acidosis

 

 

ANS:  D

When the fundamental acid–base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid–base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In metabolic acidosis, the pH is low (?6?7.35), and the HCO3 is low (?6?22). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the PCO2 is low (?6?35), indicating an attempt at compensation.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1129

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is analyzing an arterial blood gas of pH, 7.50; PCO2, 30; and HCO3, 20. What result should the nurse document for this blood gas?
a. Fully compensated metabolic alkalosis
b. Partially compensated metabolic alkalosis
c. Fully compensated respiratory alkalosis
d. Partially compensated respiratory alkalosis

 

 

ANS:  D

When the fundamental acid–base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid–base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In respiratory alkalosis, the pH is high (?7?7.45), and the PCO2 is low (?6?35). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the HCO3 is low (?6?22), indicating an attempt at compensation.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1131

TOP:   Integrated Process: Communication and Documentation

MSC:  Client Needs: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. What conditions can produce hyperventilation? (Select all that apply.)
a. Hysteria
b. Narcotics
c. Atelectasis
d. Salicylate intoxication
e. Mechanical ventilation

 

 

ANS:  A, D, E

Hysteria, salicylate intoxication, and mechanical ventilation can produce hyperventilation. Narcotics and atelectasis produce inadequate gas exchange, not hyperventilation.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1126

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. What condition or disease decreases lung compliance? (Select all that apply.)
a. Asthma
b. Atelectasis
c. Pneumothorax
d. Pulmonary edema
e. Lobar emphysema

 

 

ANS:  B, C, D

Atelectasis, pneumothorax, and pulmonary edema decrease lung compliance. Asthma and lobar emphysema increase lung compliance.

 

DIF:    Cognitive Level: Understanding     REF:   p. 1148

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is caring for an intubated child on mechanical ventilation. What interventions should the nurse implement to prevent ventilator-assisted pneumonia (VAP)? (Select all that apply.)
a. Routine oral hygiene
b. Appropriate hand hygiene
c. Limit oropharyngeal suctioning of secretions
d. Elevating the head of the bed 30 to 45 degrees
e. Wearing gloves to handle respiratory secretions

 

 

ANS:  A, B, D, E

Critically ill children on mechanical ventilation are at risk for acquisition of VAP. To prevent VAP, recommendations for nurses working with mechanically ventilated patients include appropriate hand hygiene measures; wearing gloves to handle respiratory secretions or contaminated objects; elevating the head of the bed 30 to 45 degrees; and routine oral hygiene, which includes oropharyngeal suctioning of secretions.

 

DIF:    Cognitive Level: Applying              REF:   p. 1141

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. The nurse recognizes that oxygen mist tents are rarely used for a child with respiratory distress. What are reasons for not using an oxygen mist tent? (Select all that apply.)
a. Poor access to the child
b. Cool and wet tent environment
c. Oxygen levels fall when tent is entered
d. Child may not tolerate it around the crib/bed
e. Lower oxygen concentrations cannot be achieved

 

 

ANS:  A, B, C, D

The disadvantages of using a mist tent include poor access to the child, a cool and wet tent environment, oxygen levels fall when the tent is entered, and the child may not tolerate it around the crib or bed. Lower oxygen concentrations can be achieved in the tent and is an advantage.

 

DIF:    Cognitive Level: Analyzing            REF:   p. 1156          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

COMPLETION

 

  1. The nurse is participating in a code blue on a 12-year-old child in a full respiratory arrest. The child weighs 110 lb. The health care provider has ordered an initial dose of epinephrine hydrochloride (1:10,000) given intravenously. Calculate the correct initial dose of epinephrine in mg. Record your answer using one decimal place.

_____________

 

ANS:

0.5

 

The correct calculation is:

110 lb/2.2 kg = 50 kg

Initial dose of 1:10,000 epinephrine is 0.01 mg/kg

0.01 mg 50 = 0.5 mg

 

DIF:    Cognitive Level: Applying              REF:   p. 1157          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is calculating the amount of expected urinary output for a 24-hour period on an intubated young child who weighs 22 lb. The nurse recognizes the formula to be used is 2 ml/kg/hr. What is the expected 24-hour urinary output for this child in milliliters? Record your answer below in a whole number.

_____________

 

ANS:

4840

 

Perform the calculation.

 

22/2.2 = 10 kg

 

10 ´ 2 ´ 24 = 480 ml

 

DIF:    Cognitive Level: Understanding     REF:   p. 1157

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. The nurse is calculating the amount of expected urinary output for a 24-hour period on an intubated young child who weighs 33 lb. The nurse recognizes the formula to be used is 2 ml/kg/hr. What is the expected 24-hour urinary output for this child in milliliters? Record your answer below in a whole number.

_____________

 

ANS:

720

 

Perform the calculation.

 

33/2.2 = 15 kg

 

15 ´ 2 ´ 24 = 720 ml

 

DIF:    Cognitive Level: Understanding     REF:   p. 1157

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity