Maternal And Child Health Nursing (Nurs320)
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Which of the following is the most consistent and commonly used indicator of pain in infants?
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Increased respirations
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Increased heart rate
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Thrashing of arms and legs
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Facial expression of discomfort
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This quiz for NURS320, Maternal and Child Health Nursing, assesses key competencies in managing pain in infants and children. Topics include pain indicators, assessment tools, and effective medication strategies, equipping nursing students with essential skills for pediatric care.
Quiz Preview
- 2.
Physiologic measurements in children's pain assessment are:
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Not useful as the sole indicator for pain.
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The best indicator of pain in children of all ages.
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Of most value when children also report having pain.
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Essential to determine whether a child is telling the truth about pain.
Correct Answer
A. Not useful as the sole indicator for pain.Explanation
1. Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize.
2. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report.
3. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report.
4. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 3.
Which of the following self-report pain rating scales can be used in children as young as 3 years of age?
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Poker Chip Tool
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Visual Analog Scale
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FACES Pain Rating Scale
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Word-Graphic Rating Scale
Correct Answer
A. FACES Pain Rating ScaleExplanation
1. The Poker Chip Tool has been validated for children age 4 years who have been determined to have the cognitive ability to identify the larger of 2 numbers.
2. The Visual Analog Scale can be used for children over 4 years of age, but is most appropriate for ages 7 and older.
3. The FACES Pain Rating Scale is for children as young as 3 years of age.
4. The Word-Graphic Rating Scale uses descriptive words and is recommended for children age 4-17 years.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 4.
A 5-year-old has patient-controlled analgesia (PCA) for pain management following abdominal surgery. Your explanation to the parents should include:
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The child will be pain free.
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Only the child is allowed to push the button for a bolus.
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The pump allows for a continuous basal rate and delivers a constant amount of medication to control pain.
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There is a high risk of overdose so monitoring is done every 15 minutes.
Correct Answer
A. The pump allows for a continuous basal rate and delivers a constant amount of medication to control pain.Explanation
3. The PCA prescription can be set for a basal rate for a continued infusion of pain medication to prevent pain from returning during sleep and when patient cannot control the infusion.
1. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child of 5, the parents and nurse must assess the child to ensure that adequate medication is being given.
2. A child of 5 may not be able to understand the concept of pushing a button. Evidence suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary.
4. 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.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 5.
A child who has been receiving morphine intravenously will now start receiving it orally. The nurse should anticipate that to achieve equianalgesia (equal analgesic effect), the oral dose will be which of the following?
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Same as the intravenous dose
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Greater than the intravenous dose
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One half of the intravenous dose
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One fourth of the intravenous dose
Correct Answer
A. Greater than the intravenous doseExplanation
2. Oral morphine undergoes significant metabolism from the first-pass effect. For this reason, a higher oral dose is necessary to achieve the same effect as parenteral morphine.
1. The same dose given orally will provide less pain relief.
3. A larger dose must be given to achieve an equianalgesic effect.
4. A larger dose must be given to achieve an equianalgesic effect.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: PlanningRate this question:
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- 6.
The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. Which of the following is an important consideration in managing the child's pain?
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Give only an opioid analgesic at this time.
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Increase the dosage of analgesic until the child is adequately sedated.
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Plan a preventive schedule of pain medication around the clock.
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Give the child a clock and explain when she or he can have pain medications.
Correct Answer
A. Plan a preventive schedule of pain medication around the clock.Explanation
3. For severe postoperative pain, a preventive around-the-clock schedule is necessary to prevent decreased plasma levels of medications.
1. The opioid analgesic will help for the present, but it is not an effective strategy.
2. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness.
4. This strategy is counterproductive. It focuses the child's attention on how long he or she will need to wait for pain relief.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: PlanningRate this question:
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- 7.
A significant, common side effect that occurs with opioid administration is:
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Euphoria.
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Diuresis.
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Constipation.
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Allergic reactions.
Correct Answer
A. Constipation.Explanation
3. Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem.
1. Sedation is a more common result.
2. Urinary retention, not diuresis, may occur with opiates.
4. Rarely, some individuals may have pruritus.
Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: PlanningRate this question:
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- 8.
A school-age child with cancer is being prepared for a procedure. The child says, "I have had one of these. They hurt." The nurse's response should be based on knowledge that children:
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Often lie about experiencing pain.
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Tolerate pain better than adults.
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Become accustomed to painful procedures.
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Commonly experience treatment-related moderate to severe pain when they have cancer.
Correct Answer
A. Commonly experience treatment-related moderate to severe pain when they have cancer.Explanation
4. Pain is reported by approximately 84% of children with cancer. Of these, most report it as moderate to severe, and half report the pain as highly distressing.
1. There are no data to support that children misrepresent pain experiences.
2. Pain tolerance is a complex phenomenon that is not based on age.
3. Children do not become accustomed to painful procedures.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 9.
Which of the following is the definition that best describes children with special health care needs?
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Having a loss or abnormality of structure or function
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Having a condition or barrier imposed by society, the environment, or one’s self
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Having a condition that interferes with daily function for more than 3 months a year, causes hospitalization of more than 1 month a year, or is likely to do either of these
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Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in general
Correct Answer
A. Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in generalExplanation
4. Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in general is the definition of children with special health care needs used by the federal Maternal and Child Health Bureau.
1. Having a loss or abnormality of structure or function is the definition of impairment.
2. Having a condition or barrier imposed by society, the environment, or one's self is the definition of handicap.
3. Having a condition that interferes with daily function for more than 3 months a year, causes hospitalization of more than 1 month a year, or is likely to do either of these is the definition of chronic illness.
Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: PlanningRate this question:
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- 10.
Which of the following interventions will foster a sense of independence in a toddler with disabilities?
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Help parents learn special care needs of their child.
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Help parents provide safe opportunities to explore the environment at home and in the hospital.
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Expose child to pleasurable experiences as much as possible.
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Avoid separation from family during hospitalization.
Correct Answer
A. Help parents provide safe opportunities to explore the environment at home and in the hospital.Explanation
2. Within the constraints of the disability, parents should provide safe opportunities for exploration that foster independence at home and in the hospital.
1. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.
3. Exposing the child to pleasurable experiences, especially sensory ones, is a supportive intervention. It does not support autonomy.
4. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: PlanningRate this question:
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- 11.
The father of a 9-year-old child with several physical disabilities tells 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?
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The father is experiencing denial.
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The father is expressing his own views.
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Child is using an adaptive coping style.
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Child is using a maladaptive coping style.
Correct Answer
A. Child is using an adaptive coping style.Explanation
3. 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. Their understanding of their disorder allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation.
1. The father is describing his child's behavior. He is not denying the child's limitations.
2. The father is describing his child's behavior, not his own views.
4. The father is describing a well-adapted child who has learned to accept physical limitations. This is descriptive of an adaptive coping style.
Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 12.
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, "When something is worrying you, what do you do?" This should be interpreted as which of the following?
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Verbal cue to stop crying
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Part of assessing parent’s coping skills
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Inappropriate, because parent is so upset
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Diverting the present crisis to similar situations with which parent has dealt
Correct Answer
A. Part of assessing parent’s coping skillsExplanation
2. Assessments of coping skills are important data for the nurse to obtain. This question will provide information about the marital relationship (does the parent speak 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.
1. Emotional support is necessary. The nurse should acknowledge with body and facial language how difficult the diagnosis is for the parents. Tissues should be available.
3. Assessment of coping skills is an important part of assessment information.
4. The nurse is obtaining information to help support the parent through the diagnosis.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 13.
An 8-year-old child 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?
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Recommend the parents attend school at first to prevent teasing.
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Request to visit the school.
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Refer the child to a school where the children have similar chronic disabilities.
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Discuss with the child and parents how unlikely it is that the classmates will accept the child as they did before.
Correct Answer
A. Request to visit the school.Explanation
2. Attendance at school is an important part of normalization. The nurse should ask for permission to visit the school to observe the child's behaviors with classmates and teachers.
1. A visit by the parents can be helpful, but unless the classmates are prepared for the changes, it alone will not prevent teasing.
3. The child's school experience should be normalized as much as possible. Children need the opportunity to interact with healthy peers, as well as to engage in activities with groups or clubs composed of similarly affected persons.
4. Children with special needs are encouraged to maintain and reestablish relationships with peers and to participate according to their capabilities.
Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 14.
Nursing interventions to promote coping among the siblings of a child with special needs include which of the following?
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Explain to the siblings that embarrassment is unhealthy.
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Encourage the parents not to expect siblings to help them care for the child with special needs.
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Provide information to the siblings about the child’s condition only as requested.
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Suggest to the parents ways of showing gratitude to the siblings when they help care for the child with special needs.
Correct Answer
A. Suggest to the parents ways of showing gratitude to the siblings when they help care for the child with special needs.Explanation
4. 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.
1. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner.
2. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities.
3. The siblings need to be informed 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.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 15.
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?
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“What is really wrong?”
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“Being angry is only natural.”
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“Yelling at me will not change things.”
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“I will come back when you settle down.”
Correct Answer
A. “Being angry is only natural.”Explanation
2. 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.
1. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
3. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
4. Responding with "What is really wrong?" "Yelling at me will not change things" or "I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Communication and DocumentationRate this question:
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- 16.
Which of the following best describes the 4-year-old child's concept of death?
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Death is temporary.
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Death is permanent.
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Death is inevitable at some age.
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Death is personified in various forms.
Correct Answer
A. Death is temporary.Explanation
1. Preschool-age children view death as a type of departure. It is temporary and reversible.
2. The older school-age child recognizes the permanence and inevitability of death.
3. The older school-age child recognizes the permanence and inevitability of death.
4. The young school-age child personifies death as the devil, God, or a bogeyman.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and CommunicationRate this question:
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- 17.
A school-age child with cancer is beginning to feel better now that the necessary medical procedures and treatments are not so traumatic. The child has also become very uncooperative with the parents. The nurse should explain that:
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The child is denying the seriousness of the illness.
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This is a common reaction and a way to express anger.
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More discipline is needed to deal with the uncooperativeness.
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Permissiveness is needed as child copes with a life-threatening illness.
Correct Answer
A. This is a common reaction and a way to express anger.Explanation
2. Children of this age-group are likely to exhibit fears through verbal uncooperativeness. It is the child's attempt to have some control over what is happening.
1. The child recognizes the seriousness of the illness and is attempting to exercise control.
3. Stricter discipline will not help with the child's behavior. It is necessary to allow the child to communicate feelings and provide outlets for aggression.
4. The child needs to have the support of the family and health care team. Structure is necessary with opportunities for communication and control when feasible.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and CommunicationRate this question:
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- 18.
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?
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Be available to family.
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Attempt to “lighten the mood.”
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Suggest activities to cheer up the family.
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Discourage crying until actual time of death.
Correct Answer
A. Be available to family.Explanation
1. One of the most important nursing interventions around the time of death is the availability of the nurse for the family.
2. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
3. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
4. The parents should be encouraged to express their feelings appropriately.
Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 19.
The nurse is caring for a child dying from cancer. Parents ask how they will know that the child is approaching death. The nurse's answer should include which of the following?
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Rapid pulse
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Change in respiratory pattern
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Sensation of cold although body feels hot
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Loss of hearing followed by loss of other senses
Correct Answer
A. Change in respiratory patternExplanation
2. The respiratory pattern will become slower and shallower with periodic deep sighs, followed by Cheyne-Stokes respirations and the "death rattle."
1. The pulse rate will slow.
3. The child may have sensations of heat, while the body feels cool.
4. Hearing is the last sense to fail.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/LearningRate this question:
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- 20.
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?
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Grant their request.
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Assess why they think this is necessary.
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Discourage this because it will only prolong their grief.
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Kindly explain that they need to say good-bye to their child now and leave.
Correct Answer
A. Grant their request.Explanation
1. The parents should be allowed to remain with their child after the death. The nurse can remove all the tubes and equipment and offer the parents the option of preparing the body.
2. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
3. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
4. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 21.
An adolescent girl dies in the emergency department after a car accident. Her family arrives at the hospital shortly after death. They request to see her body. Because she is disfigured from the accident, the most appropriate nursing action is which of the following?
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Contact a clergyperson to discuss this problem with them.
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Explain that their daughter is disfigured and it would be best not to see her.
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Encourage them to wait for viewing until the funeral home has prepared her body.
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Inform them of what to expect and then let them see their daughter.
Correct Answer
A. Inform them of what to expect and then let them see their daughter.Explanation
4. Prepare the family before viewing by telling them what to expect. Include bodily changes from the accident, tubes, and cold skin.
1. The parents can be asked if they would like a clergyperson present. Requesting to see their daughter is not a problem.
2. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.
3. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 22.
Parents tell the nurse that their 7-year-old daughter wants to see her brother's body and attend the funeral. Which of the following should the nurse do?
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Encourage child to attend funeral but not see the body.
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Refer the child to someone who can assess her readiness for these experiences.
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Suggest that instead of these experiences the child visit the grave site after the services are over.
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Explain that her parents or another significant person should provide support during these experiences.
Correct Answer
A. Explain that her parents or another significant person should provide support during these experiences.Explanation
4. For children of this age and older, attendance at funerals is both useful and meaningful. It helps the child acknowledge the death, honor the deceased, and receive comfort and support from a parent or significant person.
1. If an open coffin is used for the funeral, the child should be prepared for how her brother will look.
2. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.
3. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 23.
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?
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These are normal grief responses.
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The pain of the loss is usually less by this time.
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These grief responses are more typical of the early stages of grief.
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This grieving is essential until the pain is gone and the child is gradually forgotten.
Correct Answer
A. These are normal grief responses.Explanation
1. Hearing the child, troubles sleeping, feeling empty and depressed are normal grief responses. The grief response is lengthy.
2. The resolution of grief may take years, with an intensification of grief during the early years.
3. The resolution of grief may take years, with an intensification of grief during the early years.
4. The child will never be forgotten by the parents.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 24.
Therapeutic management of most children with Hirschsprung disease is primarily which of the following?
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Daily enemas
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Low-fiber diet
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Permanent colostomy
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Removal of affected piece of bowel
Correct Answer
A. Removal of affected piece of bowelExplanation
4. Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter.
1. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery.
2. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery.
3. The colostomy that is created in Hirschsprung disease is usually temporary.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 25.
A proton pump inhibitor (PPI) is ordered for an infant with gastroesophageal reflux. The nurse should include in the drug teaching that:
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The drug should be given 30 minutes before bedtime.
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Three times a day dosing has maximum effect.
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The drug can be stopped once symptoms have resolved.
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Several days may pass before full effect is reached.
Correct Answer
A. Several days may pass before full effect is reached.Explanation
4. PPIs require several days to achieve the maximum effect.
1. Optimum administration time is 30 minutes before breakfast. This allows for peak plasma levels at mealtime.
2. Once daily dosing is usually recommended.
3. Continued administration is necessary to maintain effect.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/LearningRate this question:
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- 26.
Which of the following is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract, from mouth to anus?
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Crohn disease
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Ulcerative colitis
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Meckel diverticulum
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Irritable bowel syndrome
Correct Answer
A. Crohn diseaseExplanation
1. The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus, but most often affects the terminal ileum.
2. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
3. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
4. Ulcerative colitis, Meckel diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 27.
Pyloric stenosis can best be described as which of the following?
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Dilation of pylorus
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Hypertrophy of pyloric muscle
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Hypotonicity of pyloric muscle
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Reduction of tone in the pyloric muscle
Correct Answer
A. Hypertrophy of pyloric muscleExplanation
2. Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel.
1. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
3. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
4. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: AssessmentRate this question:
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- 28.
The nurse is caring for a boy with probable intussusception. He had diarrhea before admission, but while waiting for a barium enema, he passes a normal brown stool. The most appropriate nursing action is which of the following?
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Notify physician.
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Measure abdominal girth.
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Auscultate for bowel sounds.
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Take vital signs, including blood pressure.
Correct Answer
A. Notify physician.Explanation
1. Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic and therapeutic care plan.
2. The first action would be to report the normal stool to the practitioner.
3. The first action would be to report the normal stool to the practitioner.
4. The first action would be to report the normal stool to the practitioner.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: ImplementationRate this question:
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- 29.
Which of the following is an important nursing consideration in the care of a child with celiac disease?
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Refer to a nutritionist for detailed dietary instructions and education.
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Help child and family understand that diet restrictions are usually only temporary.
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Teach proper hand washing and Standard Precautions to prevent disease transmission.
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Suggest ways to cope more effectively with stress to minimize symptoms.
Correct Answer
A. Refer to a nutritionist for detailed dietary instructions and education.Explanation
1. The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process.
2. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong.
3. Celiac disease is not transmissible.
4. Celiac disease is not stress related.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Teaching/LearningRate this question:
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- 30.
An infant with short-bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include which of the following?
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Prepare family for impending death.
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Teach family how to calculate caloric needs.
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Ensure that family can identify signs of central venous catheter infections.
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Secure TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.
Correct Answer
A. Ensure that family can identify signs of central venous catheter infections.Explanation
3. During TPN therapy care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching.
1. The prognosis for patients with short-bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN.
2. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team.
4. The tubes should not be placed under the diapers because of the risk of infection.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/LearningRate this question:
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- 31.
Nursing interventions for the child after a cardiac catheterization would include which of the following?
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Allow ambulation as tolerated.
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Monitor vital signs every 2 hours.
-
Assess the affected extremity for temperature and color.
-
Check pulses above the catheterization site for equality and symmetry.
Correct Answer
A. Assess the affected extremity for temperature and color.Explanation
3. The involved extremity is carefully assessed for signs of complications. Pulses below the catheterization site are monitored for equality and symmetry. Temperature and color are also monitored.
1. The child is maintained on bed rest or in parent's lap for 4 to 6 hours after the procedure.
2. Initially, vital signs are taken every 15 minutes.
4. Pulses are checked distal to the catheterization site.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: AssessmentRate this question:
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- 32.
Which of the following is an early sign of heart failure that the nurse should recognize?
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Tachypnea
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Bradycardia
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Inability to sweat
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Increased urinary output
Correct Answer
A. TachypneaExplanation
1. Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms.
2. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure.
3. The child may be diaphoretic.
4. Urinary output usually will be decreased.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: AssessmentRate this question:
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- 33.
Nursing care of the infant and child with heart failure would include which of the following?
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Force fluids appropriate to age.
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Monitor respirations during active periods.
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Organize activities to allow for uninterrupted sleep.
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Give larger feedings less often to conserve energy.
Correct Answer
A. Organize activities to allow for uninterrupted sleep.Explanation
3. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to minimize the child's energy expenditure.
1. The child who has heart failure has an excess of fluid.
2. Monitoring vital signs is appropriate, but minimizing energy expenditure is a priority.
4. The child often cannot tolerate larger feedings.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: EvaluationRate this question:
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- 34.
Which of the following heart defects causes hypoxemia and cyanosis because desaturated venous blood is entering the systemic circulation?
-
Coarctation of the aorta
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Atrial septal defect
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Patent ductus arteriosus
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Tetralogy of Fallot
Correct Answer
A. Tetralogy of FallotExplanation
4. Tetralogy of Fallot is a cardiac defect that has a mixed blood circulation.
1. Coarctation of the aorta is an obstructive defect. There is no mixing of oxygenated and unoxygenated blood.
2. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
3. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: PlanningRate this question:
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- 35.
The nurse suspects a child is having an adverse reaction to a blood transfusion. The first action by the nurse should be which of the following?
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Notify physician.
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Take vital signs and blood pressure and compare them with baseline.
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Dilute infusing blood with equal amounts of normal saline.
-
Stop transfusion and maintain a patent intravenous line with normal saline and new tubing.
Correct Answer
A. Stop transfusion and maintain a patent intravenous line with normal saline and new tubing.Explanation
4. Stopping the transfusion and maintaining a patent intravenous line with normal saline and new tubing is the priority nursing action. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused.
1. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
2. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
3. Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: ImplementationRate this question:
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- 36.
An important nursing consideration when caring for a child with sickle cell anemia is which of the following?
-
Refer parents and child for genetic counseling.
-
Teach parents and child how to recognize signs and symptoms of crises.
-
Help the child and family adjust to a short-term disease.
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Observe for complications of multiple blood transfusions.
Correct Answer
A. Teach parents and child how to recognize signs and symptoms of crises.Explanation
2. Parents need specific instructions on the need to watch for changes in the child's condition, including adequate hydration, and environmental concerns.
1. Genetic counseling is important, but teaching care of the child is a priority.
3. Sickle cell anemia is a long-term, chronic illness.
4. Multiple blood transfusions are an option for some children with sickle cell disease. The priority for all children with this condition is properly preparing the parents to care for them.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 37.
The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. The nurse should explain which of the following concerning narcotic analgesics?
-
They are often ordered but not usually needed.
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When they are medically indicated, children rarely become addicted.
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They are given as a last resort because of the threat of addiction.
-
They are used only if other measures, such as ice packs, are ineffective.
Correct Answer
A. When they are medically indicated, children rarely become addicted.Explanation
2. Pain is the most common and debilitating symptom experienced by patients with sickle cell disease.
1. The chronic nature of this pain can greatly affect the child's development. A multidisciplinary approach is best for its management.
3. Patient-controlled analgesia or continuous intravenous administration is usually effective.
4. Pharmacologic intervention is necessary for the pain of sickle cell crisis.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Teaching/LearningRate this question:
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- 38.
The school nurse is caring for a child with hemophilia who fell on his arm during recess. Which of the following supportive measures should the nurse do until factor replacement therapy can be instituted?
-
Apply warm, moist compresses.
-
Apply tourniquet for at least 5 minutes.
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Elevate arm above the level of the heart.
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Begin passive range of motion unless pain is severe.
Correct Answer
A. Elevate arm above the level of the heart.Explanation
3. The initial response should include elevation.
1. Cold should be applied to the arm. This will aid in vasoconstriction.
2. Pressure is effective in small areas, but would not work for an extremity.
4. Passive range of motion is not recommended. The child can perform active range of motion after the bleeding episode has resolved.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: ImplementationRate this question:
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- 39.
Nursing considerations related to the administration of chemotherapeutic drugs include which of the following?
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Anaphylaxis cannot occur, since the drugs are considered toxic to normal cells.
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Infiltration will not occur unless superficial veins are used for the intravenous infusion.
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Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates.
-
Good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary.
Correct Answer
A. Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates.Explanation
3. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and be prepared to treat extravasations if necessary.
1. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents.
2. Infiltration and extravasations are always a risk, especially with peripheral veins.
4. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.Rate this question:
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- 40.
Which of the following pediatric oncologic emergencies is caused by the rapid release of intracellular metabolites during the initial treatment of some cancers?
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Hyperleukocytosis
-
Overwhelming infection
-
Acute tumor lysis syndrome
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Superior vena cava syndrome
Correct Answer
A. Acute tumor lysis syndromeExplanation
3. Acute tumor lysis syndrome is caused by the rapid release of intracellular metabolites during the initial treatment of malignancies.
1. Hyperleukocytosis, a white blood cell count greater than 100,000/mm3, can be present at diagnosis. It is not a result of the treatment.
2. Infection may occur from bone marrow suppression that results from many chemotherapeutic agents.
4. Superior vena cava syndrome can occur from compression of the mediastinal structures by Hodgkin disease and non-Hodgkin lymphoma.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 41.
The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following?
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Petechiae, fever, fatigue
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Headache, papilledema, irritability
-
Muscle wasting, weight loss, fatigue
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Decreased intracranial pressure, psychosis, confusion
Correct Answer
A. Petechiae, fever, fatigueExplanation
1. Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia.
2. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
3. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
4. Headache, papilledema, irritability, muscle wasting, weight loss, fatigue, decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: AssessmentRate this question:
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- 42.
Which of the following statements best describes hypopituitarism?
-
Skeletal proportions are normal for age.
-
Weight is usually more retarded than height.
-
Growth is normal during the first 3 years of life.
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Most of these children have subnormal intelligence.
Correct Answer
A. Skeletal proportions are normal for age.Explanation
1. Skeletal proportions are normal for age, but these children appear young for their age.
2. Growth in height is usually more delayed than in weight.
3. Growth is normal for the first year of age, and then they follow a slowed growth curve.
4. Most of the children have normal intelligence. Often they are considered precocious because their educational ability seems to exceed their size. Emotional problems are not uncommon because of the small stature.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 43.
Which of the following should the nurse include when discussing a child's precocious puberty with the parents?
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The child is not yet fertile.
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Heterosexual interest is usually advanced.
-
Dress and activities should be appropriate to chronologic age.
-
Appearance of secondary sexual characteristics does not proceed in the usual order.
Correct Answer
A. Dress and activities should be appropriate to chronologic age.Explanation
3. Because of the early sexual maturation of the child, both family and child require extensive teaching. Included in this is the information that the child should be engaged in activities according to chronologic age.
1. Functioning sperm or ova may be produced, thereby making the child fertile at an early age.
2. Heterosexual interest is usually appropriate to chronologic age.
4. Development of the secondary sexual characteristics proceeds in the usual order.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/LearningRate this question:
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- 44.
Which of the following is the primary clinical manifestation of diabetes insipidus?
-
Oliguria
-
Glycosuria
-
Nausea, vomiting
-
Polyuria, polydipsia
Correct Answer
A. Polyuria, polydipsiaExplanation
4. Diabetes insipidus results from the hyposecretion of antidiuretic hormone. Since insufficient amounts are produced, excessive amounts of urine are produced. When allowed access to fluids, the child maintains balance with an almost insatiable thirst.
1. Oliguria is diminished urinary output. Children with diabetes insipidus have increased urinary output.
2. Glycosuria is not a manifestation of diabetes insipidus. It may be a manifestation of diabetes mellitus.
3. Nausea and vomiting are not manifestations of diabetes insipidus. They can occur with oversecretion of antidiuretic hormone.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 45.
A 13-year-old girl is brought to the clinic with the complaint of insomnia and hyperactivity. Other symptoms include gradual weight loss despite a good appetite; warm, flushed, and moist skin; and unusually fine hair. These manifestations are most suggestive of which of the following?
-
Hypothyroidism
-
Hyperthyroidism
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Hypoparathyroidism
-
Hyperparathyroidism
Correct Answer
A. HyperthyroidismExplanation
2. These symptoms are suggestive of hyperthyroidism. Other symptoms include academic difficulties resulting from a short attention span and inability to sit still, unexplained fatigue and sleeplessness, and difficulty with fine motor skills.
1. Hypothyroidism is seen with decelerated growth from chronic deprivation of thyroid hormone. Other manifestations are myxedematous skin changes (dry skin, puffiness around the eyes, sparse hair), constipation, sleepiness, and mental decline.
3. Early manifestations of hypoparathyroidism may be anxiety and mental depression, followed by paresthesia and evidence of heightened neuromuscular excitability.
4. Hyperparathyroidism results in hypercalcemia, which can be manifested by a change in behavior, gastrointestinal symptoms, and cardiac irregularities.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 46.
The nurse is caring for a child hospitalized with acute adrenocortical insufficiency. Because of the sudden, severe nature of the disease the family needs a great deal of emotional support. The most appropriate nursing action is which of the following?
-
Prepare family for impending death.
-
Prepare the family for each procedure.
-
Prepare family for long-term consequences of paralysis.
-
Reassure family that flaccid paralysis is not problematic.
Correct Answer
A. Prepare the family for each procedure.Explanation
2. By preparing the family for each procedure, the nurse is showing sensitivity to the family's emotional needs.
1. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
3. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
4. Flaccid paralysis is problematic if not reversible.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 47.
Which of the following statements best describes Cushing syndrome?
-
It is caused by excessive production of cortisol.
-
Treatment involves replacement of cortisol.
-
The major clinical features are exophthalmia and pigmentary changes.
-
Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria.
Correct Answer
A. It is caused by excessive production of cortisol.Explanation
1. Cushing syndrome is a description of the clinical manifestations caused by too much circulating cortisol. In children this is caused by a tumor or excessive and prolonged steroid therapy.
2. The treatment is reduction of circulating cortisol. If the cause is a pituitary tumor, surgery is indicated.
3. Exophthalmia is a manifestation of hyperthyroidism, not Cushing syndrome.
4. Hypertension and hypokalemia are expected findings.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 48.
The parent of a 10-year-old child with diabetes asks the nurse why home blood glucose monitoring is being recommended. The nurse should base the explanation on which of the following?
-
It is an easier method of testing.
-
Parents are better able to manage the diabetes.
-
Children have a greater sense of control over the diabetes.
-
Fewer visits to the primary care provider will be necessary.
Correct Answer
A. Children have a greater sense of control over the diabetes.Explanation
3. Blood glucose monitoring affords the child a greater sense of control. The immediate feedback allows for regulation of insulin doses.
1. Home blood glucose monitoring provides a more accurate assessment of control than urine testing.
2. Although parents are involved in the management, a 10-year-old child should be taking responsibility for testing.
4. The same number of visits will be necessary, but the blood glucose monitoring will enable better control.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
-
- 49.
A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if he can still play soccer, play baseball, and swim. The nurse's response should be based on knowledge that:
-
Exercise is contraindicated.
-
The level of activity depends on the type of insulin required.
-
Exercise is not restricted unless indicated by other health conditions.
-
Soccer and baseball are too strenuous, but swimming is acceptable.
Correct Answer
A. Exercise is not restricted unless indicated by other health conditions.Explanation
3. Exercise is encouraged for children with diabetes because it lowers blood glucose levels. Insulin and meal requirements require careful monitoring to ensure that the child has sufficient energy for exercise.
1. Exercise is highly encouraged. The decrease in blood glucose can be accommodated by having snacks available.
2. The level of activity is not dependent on the type of insulin used. Long- and short-acting insulin both may be used to compensate for the effects of training and sporting events.
4. Sports are encouraged to help regulate the insulin, and food should be adjusted according to the amount of exercise. The child needs to be cautioned to monitor responses to the exercises.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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Mar 22, 2023Quiz Edited by
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Nov 27, 2012Quiz Created by
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