The Child with a Chronic Condition or Terminal Illness

MULTIPLE CHOICE

1. A family has just learned their child has cystic fibrosis. They told the nurse “this won’t change anything, our child is not that sick.” The nurse recognizes that the family is in which stage of the grieving process?

a.
Anger and resentment
b.
Sorrow and depression
c.
Shock and disbelief
d.
Acceptance and adjustment

ANS: C

According to Kübler-Ross, denial is the initial stage of the grieving process when an individual reacts with shock and disbelief to the diagnosis of a chronic illness. Feelings of anger, resentment, sadness, and depression are part of the grieving process, after the initial response of shock and disbelief. Acceptance is the final stage of the grieving process.

DIF: Cognitive Level: Comprehension REF: p. 252

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

2. A nurse is planning care for a dying child. Which priority intervention is planned to address the primary concern parents have for the dying child?

a.
Pain
b.
Safety
c.
Food intake
d.
Fluid intake

ANS: A

The primary concern of all parents of dying children is the possibility of their child feeling pain. Although safety, eating, and hydration are important, they are not the priority concern.

DIF: Cognitive Level: Application REF: p. 264

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

3. A parent of an infant states that she will room-in while her child is hospitalized. The nurse supports her decision knowing that the major fears of infants during illness and hospitalization are:

a.
bodily injury and pain.
b.
separation from caregivers and fear of strangers.
c.
loss of control and altered body image.
d.
the unknown and being left alone.

ANS: B

The major fear of infants during illness and hospitalization are separation from caregivers and fear of strangers. Bodily injury and pain are fears of preschool and school-age children. Loss of control is a fear of children from the preschool period through adolescence. Altered body image applies to adolescents. Fear of the unknown and being left alone are applicable to preschoolers.

DIF: Cognitive Level: Comprehension REF: p. 254

OBJ: Nursing Process Step: Evaluation MSC: Psychosocial Integrity

4. A nurse has just completed a teaching session for parents about children’s understanding of death. Parents of a 5-year-old child understood the teaching if they indicate which corresponds to their child’s understanding of death?

a.
Loss of a caretaker
b.
Reversible and temporary
c.
Permanent
d.
Inevitable

ANS: B

Children in early childhood (2 to 7 years old) view death as reversible and temporary. Toddlers view death as loss of a caretaker. The school-age child and adolescent understand death is permanent. The adolescent understands death not only as permanent, but also inevitable.

DIF: Cognitive Level: Application REF: p. 260

OBJ: Nursing Process Step: Evaluation MSC: Psychosocial Integrity

5. A nurse plans to include family in the aspects of care for a dying 12-month-old child. The nurse bases this plan on the understanding that death for an infant is understood as:

a.
temporary.
b.
permanent.
c.
loss of caretaker.
d.
punishment.

ANS: C

Infants and toddlers view death as loss of a caretaker. The preschool-age child views death as temporary. The school-age child and adolescent understand the permanence of death. The preschool-age child facing impending death may view his or her condition as punishment for behaviors or thoughts.

DIF: Cognitive Level: Comprehension REF: p. 260

OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity

6. Which activity should the nurse implement for the toddler hospitalized with a chronic illness to promote autonomy?

a.
Playing with a push-pull toy.
b.
Putting a puzzle together.
c.
Playing a simple card game.
d.
Watching cartoons on TV.

ANS: A

Chronic illness may interfere in the development of autonomy, which is the major psychosocial task of the toddler. The developmentally appropriate activity for the hospitalized toddler is to play with a push-pull toy. Putting a puzzle together and playing a simple card game could frustrate the toddler and are appropriate for a preschool or school-age child. Watching cartoons on TV is passive and will not promote autonomy.

DIF: Cognitive Level: Application REF: p. 254

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

7. How can chronic illness and frequent hospitalization affect the psychosocial development of an adolescent?

a.
They can lead to feelings of inadequacy.
b.
They can interfere with parental attachment.
c.
They can block the development of identity.
d.
They can prevent the development of imagination.

ANS: C

Development of identity is the task of the adolescent. Inadequacy and inferiority refer to the school-age period. Parental attachment is a task of the infant. Development of imagination occurs in the preschool period.

DIF: Cognitive Level: Comprehension REF: p. 254

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

8. Which is an important focus of nursing care for the dying child and his or her family?

a.
Nursing care should be organized to minimize contact with the child.
b.
Adequate oral intake is crucial to the dying child.
c.
Families should be made aware that hearing is the last sense to stop functioning before death.
d.
It is best for the family if nursing care takes place during periods when the child is alert.

ANS: C

Families should be encouraged to talk to the child because verbal communication and physical touch are important both for the family and child. Nursing care should minimize disruptions but not contact. When a child is dying, fluids should be based on the child’s requests, with a focus on comfort and preventing a dry mouth. The times when the child is alert should be devoted to family contacts.

DIF: Cognitive Level: Application REF: p. 265

OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity

9. What is the most appropriate response to a school-age child who asks if she can talk to her dying sister?

a.
“You need to talk loudly so she can hear you.”
b.
“Holding her hand would be better because at this point she can’t hear you.”
c.
“Although she can’t hear you, she can feel your presence so sit close to her.”
d.
“Even though she will probably not answer you, she can still hear what you say to her.”

ANS: D

Hearing is the last sense to cease before death. Talking to the dying child is important both for the child and the family. The sibling should be encouraged to speak to the child as well as hold the child’s hand.

DIF: Cognitive Level: Application REF: p. 265

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

10. The nurse recognizes that the priority goal for the child with a chronic illness is to:

a.
maintain the intactness of the family.
b.
eliminate all stressors.
c.
achieve complete wellness.
d.
obtain the highest level of wellness.

ANS: D

To obtain the highest level of health and function possible is the priority goal of nursing of children. Maintaining the intactness of the family is a goal for the family, not specifically the child. It is not a realistic goal to eliminate all stressors because life will continue to present stressors. It is also unrealistic to achieve complete wellness because chronic illness by definition is a long-term condition either without a cure or with residual limitations.

DIF: Cognitive Level: Comprehension REF: pp. 253-254

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

11. Which is the predominant trait of the resilient family associated with chronic illness?

a.
Social separation
b.
Family flexibility
c.
Family cohesiveness
d.
Clear family boundaries

ANS: C

Family cohesiveness is the predominant trait of the resilient family. Maintaining social integration is one of the traits of a resilient family system. Family flexibility and clear family backgrounds are traits of the resilient family, but not the predominant one.

DIF: Cognitive Level: Knowledge REF: p. 251

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

12. Parents express recurrent feelings of grief, loss, and fear related to their child’s chronic condition. The nurse understands that this is:

a.
anticipatory grieving.
b.
chronic sorrow.
c.
bereavement.
d.
illness trajectory.

ANS: B

The stated recurrent feelings define chronic sorrow, which is considered a normal process involving grief that may never be resolved. Anticipatory grieving is the process of mourning, coping, interacting, planning, and psychosocial reorganization that is begun as a response to the impending loss of a loved one. Bereavement is defined as the objective condition or state of loss. Illness trajectory is defined as the impact of the disease or condition on all family members, physiological unfolding of the disease, and work organization done by the family to cope.

DIF: Cognitive Level: Comprehension REF: p. 252

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

13. Which would be a priority nursing diagnosis for the child with chronic illness?

a.
Risk for delayed development related to chronic illness or disability
b.
Chronic pain related to frequent injections
c.
Anticipatory grieving related to impending death
d.
Anxiety related to frequent hospitalizations

ANS: A

Risk for delayed development related to chronic illness or disability is the priority nursing diagnosis that would be appropriate for the majority of children with chronic illnesses. Pain is not associated with the majority of chronic illnesses. A chronic illness is one that does not have a cure. It does not mean the child will die prematurely. Frequent hospitalizations are not required for all chronic illnesses.

DIF: Cognitive Level: Application REF: p. 253

OBJ: Nursing Process Step: Nursing Diagnosis

MSC: Health Promotion and Maintenance

14. Which is the most appropriate response for the nurse when parents say that “living with this disease our child has is really hard; it’s not fair”?

a.
“Tell me about what is hard for you.”
b.
“I know exactly how you must feel.”
c.
“I know a local support group for families.”
d.
“I am going to ask the grief counselor to meet with you.”

ANS: A

The first step in supporting families and helping them deal with chronic sorrow is to listen to and recognize their pain. Telling the parents that you know how they must be feeling would not encourage parents to talk about their feelings. Each individual’s perception of a situation is different. A nurse can never know exactly how parents feel about having a child with a chronic illness. “I know a local support group for families” and “I am going to ask the grief counselor to meet with you” do not address the parent’s immediate feelings.

DIF: Cognitive Level: Application REF: p. 252

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

15. Which is the most appropriate response to a parent who tells the nurse, “I don’t want my child to know she is dying?”

a.
“I shall respect your decision. I won’t say anything to your child.”
b.
“Don’t you think she has a right to know about her condition?”
c.
“Would you like me to arrange for the physician to speak with your child?”
d.
“I’ll answer any questions she asks me as honestly as I can.”

ANS: D

Nurses can inform parents that they will not initiate any discussion with the child but that they intend to respond openly and honestly if and when the child initiates such a discussion. As the caregiver and advocate, the nurse should first meet the child’s needs. “Would you like me to arrange for the physician to speak with your child” does not address the parent’s wishes.

DIF: Cognitive Level: Application REF: p. 263

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

MULTIPLE RESPONSE

1. Which indicators of imminent death in a child should the nurse expect to assess? Select all that apply.

a.
Heart rate increases.
b.
Blood pressure increases.
c.
Respirations become rapid and shallow.
d.
The extremities become warm.
e.
Peripheral pulses become stronger.

ANS: A, C

Indicators of imminent death include the heart rate increasing, with a concomitant decrease in the strength and quality of peripheral pulses; respiratory effort declines, as evidenced by rapid, shallow respirations; and extremities are cool and cyanotic.

DIF: Cognitive Level: Comprehension REF: p. 252

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

OTHER

1. Place the stages of grieving in order starting with the initial stage and ending with the final stage.

a. Anger

b. Depression

c. Denial

d. Acceptance

e. Bargaining

ANS:

C, A, E, B, D

The stages of grieving, in order, include denial, anger, bargaining, depression, and acceptance.