Homework Lance
MULTIPLE CHOICE
1. Which is the most appropriate statement for the nurse to make to a 5-year-old child who is to have a venipuncture?
a.
“You must hold still or I’ll have someone hold you down. This is not going to hurt.”
b.
“This will hurt like a pinch. I’ll get someone to help you hold your arm still so it will be over fast and hurt less.”
c.
“Be a big boy and hold still. This will be over in just a second.”
d.
“I’m sending your mother out so she won’t be scared. You are big, so hold still and this will be over soon.
ANS: B
Honesty is the best approach and a venipuncture may hurt. Children should be told what sensation they will feel during a procedure. A 5-year-old child should not be expected to hold still, and assistance ensures safety to everyone. The nurse should not tell the child to a “be a big boy and hold still” or that it “will be over in just a second” as this is not supportive or honest. Parents should be encouraged to remain with the child unless they are extremely uncomfortable doing so.
DIF: Cognitive Level: Application REF: p. 269
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
2. The nurse should obtain informed consent for which situation?
a.
For any procedure that will be performed on a child
b.
For any invasive procedure involving a risk to a child
c.
Only if the child is not able to give consent
d.
Only if the parents are not present
ANS: B
Informed consent is required for invasive procedures that involve a risk to a child, such as lumbar puncture, chest tube insertion, and bone marrow aspirations. Informed consent is not required for procedures that are covered under the general consent to treat that is signed at admission by a parent or a guardian. Agreement with the procedure is obtained from children older than 7 years of age but does not preclude the need for informed consent from a parent. If a parent is not present and an emergency procedure requiring informed consent is needed, administrative consent must be obtained.
DIF: Cognitive Level: Application REF: pp. 270-271
OBJ: Nursing Process Step: Implementation
MSC: Safe and Effective Care Environment
3. Which nursing diagnosis is appropriate for a 5-year-old child in isolation because of immunosuppression?
a.
Spiritual distress
b.
Social isolation
c.
Diversional activity deficit
d.
Sleep disturbance
ANS: C
Children in isolation need extra attention to avoid boredom. A 5-year-old child is not developmentally advanced enough to feel spiritual distress. The main social system for a 5-year-old child is the family, who should be allowed liberal visitation. Sleep disturbances may occur during hospitalization but are not specific to isolation.
DIF: Cognitive Level: Comprehension REF: p. 273
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Safe and Effective Care Environment
4. Which nursing action is most appropriate when giving a child a sponge bath to decrease fever?
a.
Use alcohol in the bath water to lower the child’s temperature rapidly.
b.
Use cold water to hasten the procedure.
c.
Stop the sponge bath immediately if the child starts to shiver.
d.
Bathe the child for 45 to 60 minutes.
ANS: C
The procedure should be stopped immediately if the child begins to shiver. Shivering will increase the child’s temperature. Alcohol is contraindicated because of skin irritation, the risk of neurological depression from the fumes or absorption through the skin, and shivering, which results from rapid cooling. Cold water can lead to rapid cooling. Tepid water should be used for a sponge bath to reduce fever. The procedure should be stopped immediately if the child begins to shiver. Shivering will increase the child’s temperature.
DIF: Cognitive Level: Application REF: p. 279
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
5. Which action is appropriate when the nurse is bathing a small child?
a.
Test the water on the inside of the wrist or elbow for comfort.
b.
Allow children older than 2 years to bathe themselves.
c.
Check that the water temperature does not exceed 120° F.
d.
Step out of the room to give the child privacy while bathing.
ANS: A
Bath water should be warm, not hot. Water temperature can be tested on the inside of the wrist or elbow. Young children can assist with bathing but cannot bathe independently. The temperature of the water should be less than 100° F. The nurse should never leave an infant or small child unattended in the bath.
DIF: Cognitive Level: Application REF: pp. 273-274
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
6. Which is the best response for a nurse to make to a parent who has asked, “When should I start dental care for my child?”
a.
“The recommendation is for children to have a dental examination no later than 2 1/2 years.”
b.
“Children should see a dentist at least one time before kindergarten.”
c.
“The recommendation is for children to have a dental examination before first grade.”
d.
“A dental examination by 1 year of age is the current recommendation.”
ANS: A
Children should be examined by a dentist between the time the first teeth erupt and primary dentition is complete at 2 1/2 years of age. Children require regular dental examinations well before kindergarten. Six years of age is too late to begin regular dental examinations. One year of age is too young, since many children have only a few teeth at this age.
DIF: Cognitive Level: Application REF: p. 275
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
7. Which action is appropriate to promote a toddler’s nutrition during hospitalization?
a.
Allow the child to walk around during meals.
b.
Require the child to empty his or her plate.
c.
Ask the child’s parents to bring a cup and utensils from home.
d.
Select new foods for the child from the menu.
ANS: C
Using familiar items during mealtimes increases the toddler’s sense of security and control. For safety reasons, “roaming” while eating should not be permitted. The child should be seated during meals. Toddlers often use food as a source of control. Forcing a toddler to eat only increases the child’s sense of powerlessness. Toddlers also experience food jags, a normal phenomenon during which they will eat only certain foods. Hospitalization is a stressful experience for the toddler. It is not the time to introduce the child to new foods.
DIF: Cognitive Level: Application REF: pp. 275-276
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
8. Which concept is important for the nurse to know when taking a child’s temperature?
a.
The method used should be consistent.
b.
Rectal temperatures should always be taken on infants.
c.
Oral temperatures can be taken on all children older than 5 years of age.
d.
Axillary temperatures should be taken at night.
ANS: A
The method that is determined most appropriate for the child should be used consistently—the same site and device to maintain consistency and allow reliable comparison and tracking of temperatures over time. Because of the risk of rectal perforation and the intrusive nature of the procedure, rectal temperatures are measured only when no other route can be used or when it is necessary to obtain a core body temperature. Oral temperatures can be used on most children older than 6 years of age but may be inaccurate because of oral intake, oral surgery, oxygen therapy, nebulizer treatments, or crying. The method of measuring temperature should be consistent, including at night.
DIF: Cognitive Level: Application REF: p. 276
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
9. A parent calls the pediatrician’s office because her 1-year-old child has a 100° F temperature. What would be the most appropriate initial nursing response to make to the parent?
a.
“Did you feel your child’s forehead?”
b.
“Tell me about the child’s behavior.”
c.
“Has anyone in your home been sick lately?”
d.
“There is no need for concern if the child’s temperature is less than 101° F.”
ANS: B
In general, the height of the fever is not an indication of the seriousness of the illness. It is more important to note changes in the child’s behavior. If a child has a low-grade temperature and acts sick, he or she should be assessed further. Feeling a child’s forehead can give clues related to whether the child’s temperature should be measured; if it has already been measured, this would be unnecessary because it does not give accurate information about the child’s body temperature. Learning of other sick persons in the home will yield relevant information for the nurse to use in advising the parent, but it is not the best initial response. Although the height of the temperature is not an indication of the seriousness of the child’s illness, it is incorrect to tell a parent to be unconcerned about temperatures less than 101° F.
DIF: Cognitive Level: Application REF: p. 279
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
10. Which nursing action is appropriate for specimen collection?
a.
Follow sterile techniques for specimen collection.
b.
Sterile gloves are worn if the nurse plans to touch the specimen.
c.
Use standard precautions when handling body fluids.
d.
Avoid wearing gloves in front of the child and family.
ANS: C
Standard precautions should always be used when handling body fluids. Specimen collection is not always a sterile procedure. Gloves should be worn if there is a chance the nurse will be contaminated. The choice of sterile or clean gloves will vary according to the procedure or specimen. The child and family should be educated in the purpose of glove use, including the fact that gloves are used with every patient, so they will not be offended or frightened.
DIF: Cognitive Level: Application REF: p. 280
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
11. What information should the nurse include in teaching parents to care for a child’s gastrostomy tube at home?
a.
Never turn the gastrostomy button.
b.
Clean around the insertion site daily.
c.
Expect some leakage around the button.
d.
Remove the tube for cleaning once a week.
ANS: B
The skin around the tube insertion site should be cleaned with soap and water once or twice daily. The gastrostomy button should be rotated in a full circle during cleaning. Leakage around the tube should be reported to the physician. A gastrostomy tube is placed surgically. It is not removed for cleaning.
DIF: Cognitive Level: Comprehension REF: pp. 289-290
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
12. Which nursing action is the most appropriate when applying a face mask for oxygen therapy to a child?
a.
The oxygen flow rate should be less than 6 liters per minute.
b.
Make sure the mask fits properly.
c.
Keep the child warm.
d.
Remove the mask for 5 minutes every hour.
ANS: B
A properly fitting face mask is essential for adequate oxygen delivery. The oxygen flow rate should be greater than 6 liters per minute to prevent rebreathing of exhaled carbon dioxide. Oxygen delivery through a face mask does not affect body temperature. A face mask used for oxygen therapy is not routinely removed.
DIF: Cognitive Level: Application REF: p. 291
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
13. Which information is appropriate to include in the care plan for a family of a child with a tracheostomy?
a.
Suction of the tracheostomy every 2 to 4 hours or as needed
b.
Application of powder around the stoma to decrease irritation
c.
Suction catheter insertion limited to less than 30 seconds
d.
Hygiene that includes showers, not baths
ANS: A
To maintain a patent airway in a child with a tracheostomy, assessing respiratory status and suctioning every 2 to 4 hours or as needed using standard precautions are important interventions to teach families. Talc powder should be avoided because of the risk of inhalation injury from breathing the powder particles. Catheter insertion for suctioning should be less than 5 seconds to prevent hypoxia. The family should be taught to avoid getting water in the tracheostomy during bath time. Showers should be discouraged.
DIF: Cognitive Level: Application REF: pp. 293-294
OBJ: Nursing Process Step: Planning MSC: Physiological Integrity
14. Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler?
a.
Measuring oral temperature for 5 minutes
b.
Counting apical heart rate for 60 seconds
c.
Observing chest movement for respiratory rate
d.
Recording blood pressure as P/80
ANS: B
Apical pulse measurement when the child is quiet for 1 full minute is the preferred method for measuring vital signs in infants and children ages 2 years and younger. A child younger than 6 years may not be able to hold a thermometer under the tongue. The respiratory rate in infants and young children can be measured by watching abdominal movement. It may be difficult to auscultate blood pressure in infants and toddlers. Systolic pressure can be palpated and should be recorded as systolic pressure over pulse (e.g., 80/P).
DIF: Cognitive Level: Analysis REF: p. 277
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
15. Which action by a nurse is appropriate when preparing a child for a procedure?
a.
Discourage the child from crying during the procedure.
b.
Use professional terms so the child will understand what is happening.
c.
Give the child choices whenever possible.
d.
Discourage the parents from staying in the room during the procedure.
ANS: C
Allowing children to make choices gives them a sense of control. Children (and adults) should be given permission to cry. Age-appropriate language should always be used. Parents should be encouraged to stay in the room and give support to the child.
DIF: Cognitive Level: Comprehension REF: p. 270
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
16. Which is the most reliable method that indicates the end of a nasogastric tube is correctly placed?
a.
Swallowing, coughing, and gagging reflex are intact.
b.
The pH of aspirated fluid is 5 or lower.
c.
The fluid has a grassy green appearance.
d.
Insufflation of air is auscultated over the epigastrium.
ANS: B
The pH of fluid aspirated from the stomach should be 5 or lower. This is the most reliable method for indicating that a nasogastric tube is properly placed. Intact swallowing, coughing, and gagging reflexes should not be used in the determination of nasogastric tube placement. Fluid aspirated from the stomach can have a grassy green, brown, or clear, mucoid-flecked appearance, but this is not the most reliable way to determine correct placement. A whooshing or gurgling sound can be heard as air injected into the tube enters the stomach, but this is not the most reliable method for determining tube placement.
DIF: Cognitive Level: Analysis REF: p. 288
OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity
17. Which is critical for the nurse to know when using restraints on children?
a.
Use the least restrictive type of restraint.
b.
Tie knots securely so they cannot be untied easily.
c.
Secure the ties to the mattress or side rails.
d.
Remove restraints every 4 hours to assess skin.
ANS: A
When restraints are necessary, the nurse should institute the least restrictive type of restraint. Knots must be tied so that they can be easily undone for quick access to the child. The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. Restraints are removed every 2 hours to allow for range of motion, position changes, and assessment of skin integrity.
DIF: Cognitive Level: Comprehension REF: pp. 271-272
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
18. Where would the nurse locate the apical pulse on a 6-year-old child?
a.
Second right intercostal space
b.
Second intercostal space at the sternal border
c.
Fourth intercostal space lateral to the midclavicular line
d.
Fifth intercostal space at the midclavicular line
ANS: C
In children younger than 7 years of age, the apical pulse is located at the fourth intercostal space, lateral to the midclavicular line. The tricuspid valve is auscultated at the second right intercostal space. The pulmonic valve can be auscultated at the second intercostal space at the left sternal border. The apical pulse in a child older than 7 years of age is located at the fifth intercostal space in the midclavicular line.
DIF: Cognitive Level: Comprehension REF: p. 277
OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance
SHORT ANSWER
1. A nurse is totaling the intake of a child who is on oral feedings, enteral feedings, and parenteral IV fluids. During the 8 hour shift the child took 4 ounces of formula, by mouth. The child also had a supplemental feeding per gastrostomy tube that ran at 20 mL per hour for 4 hours. The child’s IV ran continuously at 25 mL per hour for the whole 8 hours. What is the child’s total intake for the 8 hour shift?
ANS:
400
Keeping accurate intake and output (I&O) measurements may be necessary for some children. Measure and record all intake: oral, enteral, and parenteral. The 4 ounces of formula = 120, the 4 hours of enteral feeding at 20 mL per hour = 80, the parenteral IV intake at 25 mL per hour for 8 hours = 200. 120 + 80 + 200 = 400 total intake for the 8 hours.
DIF: Cognitive Level: Application REF: pp. 285-286
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
OTHER
1. A nurse is collecting a nasopharyngeal culture on a school-age child. Place the steps in order from the first step the nurse should take to the last step.
a. Dip the swab tip into saline.
b. Place the swab in an appropriate culture medium.
c. Ask the child to look up.
d. Gently insert the tip of the swab into one nostril.
e. Label the specimen.
ANS:
C, A, D, B, E
To obtain a nasopharyngeal culture on a school-age child the first step is to ask the child to look up. Bend the wire so that when the swab is inserted, the tip will go beyond the back of the nares and into the pharyngeal area. Dip the swab tip into saline and gently insert it into one nostril, down to the posterior nasopharynx. Leave it in place for several seconds and then remove it. After the specimen is obtained, place the swabs in the appropriate culture media. Remove gloves and perform hand hygiene. Label the specimen with the infant/child’s name, birth date, medical record number, and the time and date of collection. Place it in a biohazard bag and send it to the laboratory with the requisition form for the test(s) to be performed.
DIF: Cognitive Level: Application REF: p. 276
OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
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