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Chronic Illness, Disability, or End-of-Life Care for the Child and Family

MULTIPLE CHOICE

1. The nurse case manager is planning a care conference about a young child who has complex health care needs and will soon be discharged home. Who should the nurse invite to the conference?
a. Family and nursing staff

b. Social worker, nursing staff, and primary care physician
c. Family and key health professionals involved in child’s care
d. Primary care physician and key health professionals involved in child’s care

ANS: C
A multidisciplinary conference is necessary for coordination of care for children with complex health needs. The family is included, along with key health professionals who are involved in the child’s care.

DIF: Cognitive Level: Analysis REF: Page 576
TOP: Integrated Process: Nursing Process: Planning
MSC: AreaofClientNeeds:SafeandEffectiveCareEnvironment:Managementof Care

2. Which of the following represents a common best practice in the provision of services to children with special needs?
a. Care is now being focused on the child’s chronologic age.
b. Children with special needs are being integrated into regular classrooms.
c. Children with special needs no longer have to be cared for by their families. d. Children with special needs are being separated into residential treatment

facilities.

ANS: B
Normalization refers to behaviors and interventions for the disabled to integrate into society by living life as persons without a disability would. For children, normalization includes attending school and being integrated into regular classrooms. This affords the child the advantages of learning with a wide group of peers.

DIF: Cognitive Level: Analysis REF: Page 578
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:SafeandEffectiveCareEnvironment:Managementof Care

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review 18-2

3. Lindsey, age 5 years, 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. The best interpretation of this situation is that:

a. this is a sign 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 are used to having expectations that are too high.

ANS: B
Parenting a child with a chronic illness can be stressful for parents. There are anticipated times that 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.

DIF: Cognitive Level: Analysis REF:
TOP: Integrated Process: Teaching/Learning
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

4. Approach behaviors are those coping mechanisms that result in a family’s movement toward adjustment and resolution of the crisis of having a child with a chronic illness or disability. Which of the following is considered an approach behavior?
a. Is unable to adjust to a progression of the disease or condition

b. Anticipates future problems and seeks guidance and answers
c. Looks for new cures without a perspective toward possible benefit
d. Fails to recognize seriousness of child’s condition despite physical evidence

ANS: B
The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. They are demonstrating positive actions in caring for their child.

DIF: Cognitive Level: Analysis REF: Page 581
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

5. 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 which of the following responses?
a. Denial

b. Guilt and anger
c. Social reintegration
d. Acceptance of child’s limitations

ANS: B

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Page 579

Pub Review 18-3

For most families, the adjustment phase is accompanied by several responses. Guilt, self-accusation, bitterness, and anger are common reactions.

DIF: Cognitive Level: Comprehension REF: Page 582
TOP: Integrated Process: Nursing Process: Planning
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

6. Which of the following nursing interventions is especially helpful in assessing parental guilt when a disability or chronic illness is diagnosed?
a. Ask the parents if they feel guilty.
b. Discuss guilt only after the parents mention it.

c. Discuss the meaning of the parents’ religious and cultural background. d. Observe for signs of overprotectiveness.

ANS: C
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 sacrifice sent by God to test their religious beliefs. The nurse can help the parents explore their religious beliefs.

DIF: Cognitive Level: Analysis REF: Page 582
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

7. 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 which of the following?
a. Sense of hopefulness

b. Sense of chronic sorrow
c. Belief that procedures are a deserved punishment d. Belief that procedures are an important part of care

ANS: C
The nurse should be particularly alert to the child who passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment.

DIF: Cognitive Level: Analysis REF: Page 582
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

8. The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child’s parents begin to yell at the nurse about a variety of concerns. Which of the following is the nurse’s best response?
a. “What is really wrong?”

b. “Being angry is only natural.”
c. “Yelling at me will not change things.”

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review 18-4

d. “I will come back when you settle down.”

ANS: B
Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate.

DIF: Cognitive Level: Comprehension REF: Page 586
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

9. A common parental reaction to a child with special needs is parental overprotection. Parental behavior suggestive of this includes which of the following?
a. Giving inconsistent discipline
b. Providing consistent, strict discipline

c. Forcing child to help self, even when not capable
d. Encouraging social and educational activities not appropriate to child’s level of

capability

ANS: A
Parental overprotection is manifested by the parents’ fear of letting the child achieve any new skill; they allow the child to avoid all discipline and cater to every desire to prevent frustration.

DIF: Cognitive Level: Analysis REF: Page 583
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

10. Most parents of children with special needs tend to experience chronic sorrow. This is characterized by which of the following?
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 and loss that occur in waves over time

ANS: D
Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time.

DIF: Cognitive Level: Analysis REF: Page 583
TOP: Integrated Process: Nursing Process: Problem Identification MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

11. Which of the following interventions will encourage a sense of autonomy in a toddler with disabilities?
a. Avoid separation from family during hospitalizations.
b. Encourage independence in as many areas as possible.

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review 18-5

c. Expose child to pleasurable experiences as much as possible. d. Help parents learn special care needs of their child.

ANS: B
Encouraging the toddler to be independent encourages a sense of autonomy. The child can be given choices about feeding, dressing, and diversional activities, which will provide a sense of control.

DIF: Cognitive Level: Analysis REF: Page 592
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

12. The feeling of guilt that the child “caused” the disability or illness is especially critical in which of the following children?
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.

DIF: Cognitive Level: Comprehension REF: Page 592
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

13. Chris, age 9 years, has several physical disabilities. His father explains to the nurse that his son concentrates on what he can, rather than cannot, do and is as independent as possible. The nurse’s best interpretation of this is which of the following?

a. The father is experiencing denial.
b. The father is expressing his own views.
c. Child is using an adaptive coping style.
d. Child is using a maladaptive coping style.

ANS: C
The father is describing a well-adapted child who has learned to accept physical limitations. These children function well at home, at school, and with peers. They have an understanding of their disorder that allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation.

DIF: Cognitive Level: Application REF: Page 584
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review 18-6

14. The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, “Whom do you talk to when something is worrying you?” This should be interpreted as which of the following? a. Inappropriate, because parent is so upset

b. A diversion of the present crisis to similar situations with which parent has dealt c. An intervention to find someone to help parent
d. Part of assessing parent’s available support system

ANS: D
These are important data for the nurse to obtain. This question will provide information about the marital relationship (whether the parent speaks to the spouse), alternate support systems, and ability to communicate. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed.

DIF: Cognitive Level: Analysis REF: Page 586
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

15. The nurse is providing support to parents at the time their child is diagnosed with chronic disabilities. The nurse notices that the parents keep asking the same questions. The nurse should do which of the following?
a. Patiently continue to answer questions.

b. Kindly refer them to someone else for answering their questions. c. Recognize that some parents cannot understand explanations.
d. Suggest that they ask their questions when they are not upset.

ANS: A
Diagnosis is one of the anticipated stress points for parents. The parents may not hear or remember all that is said to them. The nurse should continue to provide the kind of information they desire.

DIF: Cognitive Level: Application REF: Page 587
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

16. Which of the following is the most appropriate nursing intervention to promote normalization in a school-age child with a chronic illness?
a. Give child as much control as possible.
b. Ask child’s peer to make child feel normal.

c. Convince 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.

DIF: Cognitive Level: Application REF: Page 590
Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review 18-7

TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

17. Nursing interventions to help the siblings of a child with special needs cope include which of the following?
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 they

request it.
d. Suggest to the parents ways of showing gratitude to the siblings who help care

for the child with special needs.

ANS: D
The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked to take on additional responsibilities to help the parents to care for the child. The parents should show gratitude, such as an increase in allowance, special privileges, and verbal praise.

DIF: Cognitive Level: Analysis REF: Page 590
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

18. The parents of a child born with disabilities ask the nurse for advice about discipline. The nurse’s response should be based on knowledge that discipline is:
a. essential for the child.
b. too difficult to implement with special-needs child.

c. not needed unless child becomes problematic. d. best achieved with punishment for misbehavior.

ANS: A
Discipline is essential for the child. It provides boundaries on which to test out their behavior and teaches them socially acceptable behaviors.

DIF: Cognitive Level: Application REF:
TOP: Integrated Process: Teaching/Learning
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

19. Kelly, age 8 years, will soon be able to return to school after an injury that resulted in several severe, chronic disabilities. Which of the following is the most appropriate action by the school nurse?
a. Recommend that Kelly’s parents attend school at first to prevent teasing.

b. Prepare Kelly’s classmates and teachers for changes they can expect.
c. Refer Kelly to a school where the children have chronic disabilities similar to

hers.
d. Discuss with Kelly and her parents the fact that her classmates will not accept

her as they did before.
Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Page 591

Pub Review 18-8

ANS: B
Attendance at school is an important part of normalization for Kelly. The school nurse should prepare teachers and classmates about her condition, abilities, and special needs.

DIF: Cognitive Level: Application REF: Page 593 | Page 594 TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

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

ANS: C
Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence.

DIF: Cognitive Level: Application REF:
TOP: Integrated Process: Teaching/Learning
MSC: AreaofClientNeeds:PsychosocialIntegrity:CopingMechanisms

21. Which of the following terms best describes a multidisciplinary approach to the management of a terminal illness that focuses on symptom control and support? a. Dying care
b. Curative care

c. Restorative care d. Palliative care

ANS: D
This is one of the definitions of palliative care. The goal of palliative care is the achievement of the highest possible quality of life for patients and their families.

DIF: Cognitive Level: Comprehension REF: Page 595
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:End-of-LifeCare

22. Which of the following best describes how preschoolers react to the death of a loved one?

a. Preschooler is too young to have a concept of death.
b. Preschooler may feel guilty and responsible for the death.
c. Grief is acute but does not last long at this age.
d. Grief is usually expressed in the same way in which the adults in the

preschooler’s life are expressing grief. ANS: B

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Page 594

Pub Review 18-9

Because of egocentricity, the preschooler may feel guilty and responsible for the death.

DIF: Cognitive Level: Comprehension REF: Page 598
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

23. A preschooler is found digging up a pet bird that was recently buried after it died. The best explanation for this behavior is which of the following?
a. He has a morbid preoccupation with death.
b. He is looking to see if a ghost took it away.

c. The loss is not yet resolved, and professional counseling is needed. d. Reassurance is needed that the pet has not gone somewhere else.

ANS: D
The preschooler can recognize that the pet has died but has difficulties with the permanence. Digging up the bird gives reassurance that the bird is still present.

DIF: Cognitive Level: Comprehension REF: Page 598
TOP: Integrated Process: Nursing Process: Problem Identification MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

24. At what age do most children have an adult concept of death as being inevitable, universal, and irreversible?
a. 4 to 5 years
b. 6 to 8 years

c. 9 to 11 years d. 12 to 16 years

ANS: C
By age 9 to 11 years, children have an adult concept of death. They realize that it is inevitable, universal, and irreversible.

DIF: Cognitive Level: Comprehension REF: Page 598
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

25. Which of the following is most descriptive of a school-age child’s reaction to death? a. Is very interested in funerals and burials
b. Has little understanding of words such as forever
c. Imagines the deceased person to be still alive

d. Has an idealistic view of world and criticizes funerals as barbaric

ANS: A
The school-age child is interested in postdeath services and may be inquisitive about what happens to the body.

DIF: Cognitive Level: Comprehension REF: Page 598
Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review

18-10

TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

26. At what developmental period do children have the most difficulty coping with death, particularly if it is their own?
a. Toddlerhood
b. Preschool

c. School-age d. Adolescence

ANS: D
Adolescents, because of their mature understanding of death, remnants of guilt and shame, and issues with deviations from normal, have the most difficulty coping with death.

DIF: Cognitive Level: Comprehension REF: Page 598
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

27. A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should explain that:
a. this will help the child cope effectively by denial.

b. this attitude is helpful to give parents time to cope.
c. terminally ill children know when they are seriously ill.
d. terminally ill children usually choose not to discuss the seriousness of their

illness.

ANS: C
The child needs honest and accurate information about the illness, treatments, and prognosis. Children, even at a young age, realize that something is seriously wrong and that it involves them. The nurse should help understand the importance of honesty.

DIF: Cognitive Level: Analysis REF: Page 597
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

28. A cure is no longer possible for a young child with cancer. The nursing staff recognizes that the goal of treatment must shift from cure to palliation. Which of the following is an important consideration at this time?
a. The family is included in the decision to shift the goals of treatment.

b. The decision must be made by the health professionals involved in the child’s care.

c. The family needs to understand that palliative care takes place in the home. d. The decision should not be communicated to the family because it will

encourage a sense of hopelessness.
Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review

18-11

ANS: A
When the child reaches the terminal stage, the nurse and physician should explore the family’s wishes. The family should help decide what interventions will occur as they plan for their child’s death.

DIF: Cognitive Level: Analysis REF: Page 597
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:End-of-LifeCare

29. The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their child one more time. The nurse should do which of the following?
a. Grant their request.

b. Assess why they feel this is necessary.
c. Discourage this because it will only prolong their grief.
d. Kindly explain that they need to say good-bye to their child now and leave.

ANS: A
The parents should be allowed to remain with their child after the death. The nurse can remove all of the tubes and equipment and offer the parents the option of preparing the body.

DIF: Cognitive Level: Analysis REF: Page 604
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

30. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still “hear” the child’s voice and have trouble sleeping. They describe feeling “empty” and depressed. The nurse should recognize which of the following? a. These are normal grief responses.

b. The pain of the loss is usually less by this time.
c. These grief responses are more typical of the early stages of grief.
d. This grieving is essential until the pain is gone and the child is gradually

forgotten.

ANS: A
These are normal grief responses. The process of grief work is lengthy.

DIF: Cognitive Level: Comprehension REF: Page 606
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

31. At the time of a child’s death, the nurse tells his mother, “We will miss him so much.” The best interpretation of this is that the nurse is doing which of the following?
a. Pretending to be experiencing grief

b. Expressing personal feelings of loss
Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review

18-12

c. Denying the mother’s sense of loss
d. Talking when listening would be better

ANS: B
A patient’s death is one of the most stressful aspects of critical care or oncology nursing. Nurses experience reactions similar to those of family members because of their involvement with the child and family during the illness. Nurses often have feelings of personal loss when a patient dies.

DIF: Cognitive Level: Analysis REF: Page 607
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

32. Which of the following is an appropriate nursing intervention when providing comfort and support for a child when death is imminent?
a. Limit care to essentials.
b. Avoid playing music near child.

c. Explain to child need for constant measurement of vital signs. d. Whisper to child instead of using normal voice.

ANS: A
When death is imminent, care should be limited to interventions for palliative care.

DIF: Cognitive Level: Application REF: Page 604
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:End-of-LifeCare

33. The nurse is providing support to a family who is experiencing anticipatory grief related to their child’s imminent death. Which of the following is an appropriate nursing intervention?
a. Be available to family.

b. Attempt to “lighten the mood.”
c. Suggest activities to cheer up the family.
d. Discourage crying until actual time of death.

ANS: A
One of the most important nursing interventions around of death is the availability of the nurse for the family.

DIF: Cognitive Level: Application REF: Page 606
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:GriefandLoss

34. The nurse and a new nurse are caring for a child who will require palliative care. Which of the following statements made by the new nurse would indicate a correct understanding of palliative care?
a. “Palliative care serves to hasten death and make the process easier for the

family.”
Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Pub Review

18-13

  1. “Palliative care provides pain and symptom management for the child.”
  2. “The goal of palliative care is to place the child in a hospice setting at the end of

life.”

  1. “The goal of palliative care is to act as the liaison between the family, child, and

other health care professionals.”

ANS: B
One of the goals of palliative care is to provide pain and symptom management.

DIF: Cognitive Level: Application REF: Page 595
TOP: Integrated Process: Nursing Process: Planning
MSC: AreaofClientNeeds:SafeandEffectiveCareEnvironment:Managementof Care

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

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Health Problems of School-Age Children and Adolescents

Impact of Cognitive or Sensory Impairment on the Child and Family