Description

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-3

Question 6

Type: MCSA

A nurse is assessing language development in all the infants presenting at the physician’s office for well-child visits. The nurse would want to evaluate the child further who is not able to verbalize the words “dada” and “mama” by the age of:

1. 18 months.
2. 8 months.
3. 5 months.
4. 12 months.

Correct Answer: 4

Rationale 1: By the age of 18 months, the child will have names for more people than just “mama” and “dada.”

Rationale 2: By eight months, infants will be making the sounds “mamamamam” and “dadadada” because they like to repeat sounds. At this time, they do not use these as names for the parents.

Rationale 3: A five-month-old infant makes sounds, but the sounds are not words.

Rationale 4: A child should be able to verbalize “mama” or “dada” to identify her parents by one year of age.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5-4

Question 7

Type: MCSA

Two three-year-olds are playing in a hospital playroom together. One is working on a puzzle, while the other is stacking blocks. The mother of one of the children scolds them for not sharing their toys. The nurse counsels this mother that this is normal developmental behavior for this age, and the term for it is:

1. Cooperative play.
2. Solitary play.
3. Parallel play.
4. Associative play.

Correct Answer: 3

Rationale 1: Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole. The school-age child participates in cooperative play.

Rationale 2: Solitary play is when a child plays alone. Infants’ play style is described as solitary.

Rationale 3: Parallel play is when two or more children play together, each engaging in her own activities.

Rationale 4: Associative play is characterized by children interacting in groups and participating in similar activities. Preschoolers’ play style is associative.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5

Question 8

Type: MCSA

A neonatal nurse who encourages parents to hold their baby and provides opportunities for kangaroo care most likely is demonstrating concern for which aspect of the infant’s psychosocial development?

1. Attachment
2. Assimilation
3. Resilience
4. Centration

Correct Answer: 1

Rationale 1: Attachment is a strong emotional bond between a parent and child that forms the foundation for the fulfillment of the basic need of trust in the infant.

Rationale 2: Assimilation describes the child’s incorporation of new experiences.

Rationale 3: Resilience is the ability to maintain healthy function even under significant stress and adversity.

Rationale 4: Centration is the ability to consider only one aspect of a situation at a time.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5

Question 9

Type: MCSA

While trying to inform a five-year-old girl about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. The nurse’s best response would be:

1. “You must be so excited to have a new puppy! They are so much fun. Now let me tell you again about going downstairs in a wheelchair to a special room.”
2. “Please stop talking about your puppy. I need to tell you about your CT scan.”
3. “I’ll come back when you are ready to talk with me more about your CT scan.”
4. Ignore the child’s responses and continue discussing the procedure.

Correct Answer: 1

Rationale 1: When a child becomes engaged in a collective monologue, it is best to respond to the content of her conversation and then attempt to reinsert facts about the content that needs to be covered.

Rationale 2: Asking the child to stop talking about her puppy and then abruptly talking about the CT scan will alienate the child and possibly make her shut down.

Rationale 3: Coming back later is not usually an option, as radiological exams are scheduled for a certain time. The nurse needs to address the inattention but should listen for a few moments before directing the patient’s attention.

Rationale 4: Ignoring the child’s obvious lack of attention will not help prepare her for the upcoming procedure.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5

Question 10

Type: MCSA

The mother of a six-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. The nurse caring for the child should assure the mother that this is a normal response for a child who has undergone surgery and that it is a coping mechanism that children sometimes use called:

1. Repression.
2. Rationalization.
3. Fantasy.
4. Regression.

Correct Answer: 4

Rationale 1: Repression is the involuntary forgetting of uncomfortable situations.

Rationale 2: Rationalization is an attempt to make unacceptable feelings acceptable.

Rationale 3: Fantasy is a creation of the mind to help deal with an unacceptable fear.

Rationale 4: The correct answer is regression, which is a return to an earlier behavior.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6

Question 11

Type: MCSA

Prior to giving an intramuscular injection to a two-and-a-half-year-old child, the most appropriate statement by the nurse would be:

1. “It is all right to cry. I know that this hurts. After we are done, you can go to the box and pick out your favorite sticker.”
2. “We will give you your shot when your mommy comes back.”
3. “This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here. Then I will hold the needle like this and say ‘one, two, three, go’ and give you your shot. After the shot is over with, I will hold the cotton ball until it stops bleeding and then put the Band-Aid on. Are you ready?”
4. “This is a magic sword that will give you your medicine and make you all better.”

Correct Answer: 1

Rationale 1: The most appropriate response would be to acknowledge the child’s feelings and give him something to look forward to.

Rationale 2: Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time.

Rationale 3: Giving elaborate descriptions and using colorful language are inappropriate because the instructions are unclear and lengthy.

Rationale 4: The nurse should not make statements that are not true and might confuse the child.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-7

Question 12

Type: MCSA

A 14-year-old with cystic fibrosis suddenly becomes noncompliant with the medication regimen. The intervention by the nurse that would most likely improve compliance would be to:

1. Give the child a computer-animated game that presents information on the management of cystic fibrosis.
2. Set up a meeting with some older teens who have cystic fibrosis and have been managing their disease effectively.
3. Arrange for the physician to sit down and talk to the child about the risks related to noncompliance with medications.
4. Discuss with the child’s parents that privileges, such as a cell phone, can be taken away if compliance fails to improve.

Correct Answer: 2

Rationale 1: Interest in games might begin to wane at this age.

Rationale 2: Providing an adolescent with positive role models who are in her peer group is the intervention most likely to improve compliance.

Rationale 3: Adult opinions, even from a physician, could be viewed negatively and challenged.

Rationale 4: Threatening punishment could further incite rebellion.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-7

Question 13

Type: MCSA

The home health nurse is visiting a family at home when the toddler has an “accident” and has a bowel movement in his diaper. The mother becomes angry with the child and calls him a baby for messing himself. The nurse considers Erikson’s theory and recognizes that the mother’s behavior may have an effect on the child’s:

1. Cognitive development.
2. Sense of independence.
3. Conscience.
4. Development of superego.

Correct Answer: 2

Rationale 1: Erikson’s theory is related to psychosocial development. The mother’s criticism will not affect the child’s ability to think.

Rationale 2: Erikson’s toddler stage is autonomy (independence) versus shame and doubt.

Rationale 3: Conscience is what controls our knowledge of right and wrong and is a component of Kohlberg’s theory.

Rationale 4: In Freudian theory, the superego is the moral and ethical system of the personality.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4

Question 14

Type: MCSA

The clinic administrator has suggested that the nurse teach all children newly diagnosed with diabetes in a single class to save nursing time. The children recently diagnosed range in age from 6 to 15. The argument the nurse will use in to advocate for more than one group session would be based on:

1. Freud’s theory of psychosexual development, which states that the six-year-old child’s sexual energy is at rest while the adolescent has developed mature sexuality.
2. Erikson’s psychosocial theory, which discusses how children learn to relate to others.
3. Piaget’s cognitive development theory, which says the six-year-old learns by concrete examples while the 15-year-old can think abstractly.
4. Kohlberg’s theory, which says the young child is conventional in his thinking and will want to learn to please others while the older child can internalize values and will learn for his own principles.

Correct Answer: 3

Rationale 1: This theory would not explain why it would be best to separate the group by age.

Rationale 2: Erikson’s theory is about relationships, not learning ability.

Rationale 3: The younger child will need to handle the equipment and observe demonstrations while the older child will require more discussion and less demonstration.

Rationale 4: Kohlberg’s theory may explain the reasons the child learns the material but does not discuss the learning style.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4

Question 15

Type: SEQ

As children grow and develop, their style of play changes. Place the following descriptions of play styles in order from infancy to school-age.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Plays beside but not with other children

Choice 2. Plays games with other children and is able to follow the rules of the game

Choice 3. Plays alone with play directed by others

Choice 4. Plays with others in loose groups

Correct Answer: 3,1,4,2

Rationale 1: This describes parallel play, seen in toddlers.

Rationale 2: This describes cooperative play, seen in the school-age child.

Rationale 3: This describes infant style play, called solitary play.

Rationale 4: This describes associative play, which is seen in the preschooler.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-3

Question 16

Type: MCSA

A 10-year-old child has been struggling with his self-esteem. Which activity would best help this child have a positive resolution of Erikson’s Industry versus Inferiority stage?

1. Playing sports with his older brother and the brother’s friends.
2. Have his mother compliment him when he completes his homework.
3. Encourage the child to participate in boy scouts and earn badges.
4. Suggest to the mother that she allow the child to babysit his younger siblings.

Correct Answer: 3

Rationale 1: This would not help the child develop a positive self-esteem because the older boys will be more skilled at the sport than this child.

Rationale 2: Positive reinforcement is beneficial but does not support the development of Industry.

Rationale 3: The badges will be a visible documentation of his accomplishments.

Rationale 4: The 10-year-old cannot safely babysit the younger children, and this is unrelated to Erikson’s sense of industry.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5

Ball, Child Health Nursing, 3/E
Chapter 7

Question 1

Type: MCSA

During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. Which finding would strongly suggest this disorder?

1. Asymmetric thigh and gluteal folds
2. Positive Babinski’s reflex
3. A negative Moro reflex
4. Flat soles with prominent fat pads

Correct Answer: 1

Rationale 1: Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip and require follow-up with an ultrasound.

Rationale 2: A positive Babinski’s reflex is a normal finding in a newborn.

Rationale 3: The Moro reflex involves both arms and legs. A positive Moro reflex is normal in the newborn. The absence of the Moro can indicate a brain or tissue injury.

Rationale 4: Flat soles are normal in newborns.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-1

Question 2

Type: MCSA

The nurse is taking a health history from the family of a three-year-old child. Which statement or question by the nurse would be most likely to establish rapport and elicit an accurate response from the family?

1. “Tell me about the concerns that brought you to the clinic today.”
2. “Does any member of your family have a history of asthma, heart disease, or diabetes?”
3. “Hello, I would like to talk with you and get some information about you and your child.”
4. “You will need to fill out these forms; make sure that the information is as complete as possible.”

Correct Answer: 1

Rationale 1: Asking the parents to talk about their concerns is an open-ended question and one that is more likely to establish rapport and an understanding of the parents’ perceptions.

Rationale 2: Asking about a number of items at once might be confusing to the family.

Rationale 3: Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed will be even more effective at establishing rapport and also getting more accurate, pertinent information.

Rationale 4: Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified by the nurse directing the interview.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-1

Question 3

Type: MCSA

A nurse working in the newborn nursery notes that an infant is having frequent episodes of apnea lasting 10 to15 seconds without any changes in color or decreases in heart rate. Which intervention would be the most appropriate?

1. Continue to observe the infant and call the physician if the apnea lasts longer than 20 seconds.
2. Suction the infant’s mouth and nares.
3. Call the physician immediately.
4. Turn the infant on its right side.

Correct Answer: 1

Rationale 1: Apnea lasting less than 20 seconds is a normal finding in newborns as long as there is no associated cyanosis or bradycardia, so continued observation is the most appropriate intervention.

Rationale 2: There is no indication that suctioning is needed.

Rationale 3: It is unnecessary to inform the physician, as apnea lasting 10 to 15 seconds is normal in a newborn.

Rationale 4: Turning the baby is not necessary, as apnea lasting 10 to 15 seconds in a newborn is normal.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-3

Question 4

Type: MCSA

The nurse is completing a physical examination of a four-year-old child. The best position in which to place the child for assessment of the genitalia would be:

1. Supine, with legs at a 50-degree angle.
2. Right side-lying.
3. In prone position, with knees drawn up under the body.
4. Frog-leg position.

Correct Answer: 4

Rationale 1: The child will not tolerate the legs at a 50-degree angle for long.

Rationale 2: There is no reason for a side-lying position, and the child will not tolerate holding the top leg up for long.

Rationale 3: Prone with knees drawn up will allow assessment of the anus, but it will not allow for visualization of the vaginal area.

Rationale 4: Having the child lie supine, flexing her knees and pulling them up to a frog-legged position, allows for accurate assessment of the genitalia and is well tolerated by the majority of children.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5

Question 5

Type: SEQ

Put the following nursing assessments of a toddler in the best order for the nurse to proceed (from first assessment to last assessment).

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Auscultation of chest

Choice 2. Examination of eyes, ears, and throat

Choice 3. Palpation of abdomen

Choice 4. General appearance

Correct Answer: 4,1,3,2

Rationale 1: Auscultation usually is less threatening to the toddler than is palpation, especially if the nurse first demonstrates using the stethoscope on a parent or a toy.

Rationale 2: The most uncomfortable, most invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat; therefore, this assessment should be performed last.

Rationale 3: Palpation can be more threatening than is observing or listening, so it should be completed after both.

Rationale 4: The nurse will begin the assessment by looking at the child. This can be done while the mother is holding the child and the nurse is talking to the mother. This environment will be neutral for the child and will not cause anxiety.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7-5

Question 6

Type: MCSA

A very concerned 14-year-old boy presents to the clinic because of an enlargement of his left breast. Except for the breast enlargement, the client’s history and physical are normal. The most appropriate intervention for the nurse to implement next would be to inform the child that:

1. This is a normal finding in adolescent males and that the breast tissue generally regresses by the time of full sexual maturity.
2. His condition is related to a high-fat diet and that limiting fat intake usually will resolve the enlargement over a period of a couple of months.
3. A pediatric endocrine consult is being arranged.
4. The healthcare provider is arranging a surgical consult for him.

Correct Answer: 1

Rationale 1: Gynecomastia, or breast enlargement, is a normal finding in adolescent males as they develop toward sexual maturity.

Rationale 2: The breast enlargement is not related to fat content but is normal in developing adolescent males.

Rationale 3: This is a normal finding, and an endocrine consult is not required.

Rationale 4: There is no reason for a surgical consult, as this is normal for adolescent males.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

Question 7

Type: MCSA

A nurse caring for a nine-year-old notices some swelling in the child’s ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation. Based on these physical findings, the nurse would be most concerned with assessing:

1. Skin integrity, especially in the lower extremities.
2. Level of consciousness.
3. Urine output.
4. Range of motion and ankle mobility.

Correct Answer: 3

Rationale 1: While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 2: While there may be an underlying condition causing the edema that could later result in changes in level of consciousness, assessing level of consciousness based on these findings is unlikely to elicit the cause of the child’s edema.

Rationale 3: Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney and cardiac disorders. Decreases in urine output also can indicate compromise in the renal and cardiac systems.

Rationale 4: While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 8

Type: MCSA

The nurse is caring for an infant diagnosed with “failure to thrive.” The nurse observes the physician taking blood pressures in all four extremities and recognizes that the physician suspects which congenital cardiac defect?

1. Tetralogy of Fallot
2. Ventricular septal defect
3. Pulmonary atresia
4. Coarctation of the aorta

Correct Answer: 4

Rationale 1: There are minimal differences between upper and lower blood pressure readings in tetralogy of Fallot.

Rationale 2: There are minimal differences between upper and lower blood pressure readings in ventricular septal defect.

Rationale 3: There are minimal differences between upper and lower blood pressure readings in pulmonary atresia.

Rationale 4: Normally, blood pressures in the lower extremities are the same or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities, and so lower extremity blood pressure readings are significantly lower than upper-extremity readings.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 9

Type: MCMA

A seven-year-old presents to the clinic with an exacerbation of asthma symptoms. On physical exam, the nurse would expect which of the following findings?

Standard Text: Select all that apply.

1. Increased tactile fremitus
2. Decreased vocal resonance
3. Bronchophony
4. Decreased tactile fremitus
5. Wheezing

Correct Answer: 2,4,5

Rationale 1: An increase in tactile fremitus is indicative of pneumonia.

Rationale 2: Asthma causes a decreased vocal resonance, as edema makes it more difficult for the sound to project.

Rationale 3: Bronchophony is an increase in the intensity and clarity of transmitted sounds that also is indicative of pneumonia.

Rationale 4: The air trapping in the lungs that occurs with asthma causes a decrease in the sensation of vibrations or a decreased tactile fremitus.

Rationale 5: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, and it is a condition frequently present in asthma exacerbations.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 10

Type: MCSA

While inspecting a five-year-old child’s ears with an otoscope, the nurse notes that the right membrane is red and there is an absence of light reflex. In view of these findings, which vital sign parameter would most concern the nurse?

1. Heart rate
2. Temperature
3. Blood pressure
4. Respirations

Correct Answer: 2

Rationale 1: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.

Rationale 2: The red finding indicates that there is probably infection in the middle ear while the absence of life reflex indicates a bulging tympanic member, which is also associated with infection.

Rationale 3: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.

Rationale 4: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 11

Type: MCSA

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would the nurse suspect as having an ongoing disease process?

1. Genitourinary
2. Cardiac
3. Gastrointestinal
4. Respiratory

Correct Answer: 3

Rationale 1: Tenting of the skin and dry mucous membranes could be signs of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 2: Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

Rationale 3: This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system.

Rationale 4: Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

Question 12

Type: SEQ

While evaluating development of children, the nurse notes that the development of secondary sexual characteristics follows a typical pattern. Place the appearance of secondary sexual characteristics in the female in order of appearance from earliest to latest.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Appearance of pubic hair

Choice 2. Menarche

Choice 3. Breast budding

Choice 4. Breast Tanner stage 5, areola strongly pigmented

Correct Answer: 3,1,2,4

Rationale 1: Pubic hair is the second stage of Tanner development occurring around 11 years of age.

Rationale 2: The onset of menstruation usually occurs after the appearance of the first pubic hair.

Rationale 3: According to Tanner stages, the first stage of pubertal development in girls is the development of palpable glandular tissue of the breasts. Breast buds usually develop between 9 and 14 years of age.

Rationale 4: This is the final stage of breast development according to Tanner stage. It usually occurs between 12 and 18 years of age.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6

Question 13

Type: MCMA

The policy of the pediatric clinic is that head circumferences are performed at each visit, if appropriate. The nurse should plan to check head circumferences on which of the children being seen today?

Standard Text: Select all that apply.

1. One-month-old child who is coming for his first well-child visit
2. Two-month-old child with failure to thrive
3. Nine-month-old child with otitis media
4. 18-month-old well-child visit for a child with Down’s syndrome

Correct Answer: 1,2,3,4

Rationale 1: The fontanels are open and the head will increase in size until two years of age.

Rationale 2: The posterior fontanel is closed or closing. The anterior fontanel is open and head circumference will increase. The head circumference should be monitored to make sure the failure to thrive is not affecting brain development.

Rationale 3: The anterior fontanel is still open, and the head circumference is still increasing slightly. Failure to see the increase could indicate the sutures have closed prematurely. The otitis media diagnosis is unrelated to the general assessment findings.

Rationale 4: The anterior fontanel is closed or closing. The head circumferences should be evaluated until the child is two years old. The diagnosis of Down’s syndrome does not change the need to monitor the child’s progress.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-8

Question 14

Type: MCSA

The nurse wants to do a quick evaluation of a one-month-old infant’s hearing. Which assessment will provide the best information?

1. Examining the ear canal with an otoscope
2. Using a vibrating tuning fork placed against the child’s skull
3. Using tympanometry
4. Using a noisemaker in the infant’s presence to evaluate the child’s response

Correct Answer: 4

Rationale 1: Inspection of the ear canal and membrane will not provide any information on the infant’s hearing ability.

Rationale 2: In a school-age child, this will test bone conduction, but it is not appropriate for an infant.

Rationale 3: Tympanometry is a tool to evaluate the movement of the tympanic membrane. Although related to sound transmission, it is not the best response.

Rationale 4: This is a quick, simple evaluation of the child’s ability to hear sounds. The child’s response can be a stopping of activity, widening of the eyes, or turning toward the sound.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7-5

Question 15

Type: MCSA

To accurately access blood pressure on a child, the nurse would select a cuff:

1. By the cuff label—infant, child, adult.
2. That covers 2/3 of the upper arm with a bladder that wraps around at least 80% of the circumference of the arm.
3. Based on availability as the size of the cuff will not influence the blood pressure.
4. That extends up to 50 % of the upper arm and the bladder covers 1/4 of the circumference of the arm.

Correct Answer: 2

Rationale 1: This does not determine the size of the cuff by the size of the child. In addition, the arm may not be used for the blood pressure assessment.

Rationale 2: This is an accurate measurement to determine cuff size.

Rationale 3: Blood pressure readings will be inaccurately high or low based on whether the cuff is too large or too small.

Rationale 4: This is incorrect and will result in a cuff that is too small.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5

Question 16

Type: MCSA

While assessing a seven-year-old girl, the nurse notices a regular—irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. What is the most appropriate action for the nurse to take next?

1. Record the finding as normal.
2. Notify the physician.
3. Schedule an EKG.
4. Ask the mother if a murmur has been detected before.

Correct Answer: 1

Rationale 1: This is sinus arrhythmia and is a normal finding in children but not in adults.

Rationale 2: This is a normal finding. It should be recorded, not reported.

Rationale 3: Nurses do not order tests, including EKGs.

Rationale 4: There is no evidence of a murmur in the stem. This is a normal finding.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-3

Question 17

Type: MCSA

While assessing the blood pressure of an eight-year-old child, the nurse notes the following: Systolic sound is heard at 98, but the sound continues until it reaches 0. There is a distinct sound softening at 48. How should the nurse record this finding?

1. 98/48
2. 98/48/0
3. 98/0
4. 48/0

Correct Answer: 2

Rationale 1: This is not the correct documentation. Korotkoff sounds were heard down to 0 mmHg.

Rationale 2: This documentation correctly records the nurse’s findings.

Rationale 3: This is not the correct documentation as it does not include the qualitative change at 48.

Rationale 4: This reading eliminates the systolic sound.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-5

Question 18

Type: MCMA

While assessing newborns, the nurse should differentiate normal findings from findings which require further evaluation and intervention. Which would be normal newborn findings?

Standard Text: Select all that apply.

1. Swelling over the occiput that crosses suture lines
2. Tiny white papules located primarily on the nose and chin
3. Tiny red macules and pustules that come and go, primarily on the trunk and extremities
4. When the Moro reflex is elicited, the right arm extends and returns to the body. The left arm remains resting against the chest.
5. Greenish discoloration of skin over the entire body that is not removed by the initial bath

Correct Answer: 1,2,3

Rationale 1: By crossing suture lines, this finding indicates it is caput succedaneum, a normal finding after vaginal delivery. No further evaluation or treatment is needed.

Rationale 2: This is a description of milia, a normal finding. No further care is required.

Rationale 3: This is a description of erythema toxicum, a normal newborn finding that requires no further treatment.

Rationale 4: This Moro reflex is incomplete. Further evaluation is necessary to determine if there has been injury to the right arm and/or shoulder.

Rationale 5: This is a description of a meconium-stained newborn. The passage of meconium has occurred at a more distant time, leading to the staining. The child will need to be evaluated for meconium aspiration.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-3

Question 19

Type: MCSA

The nurse is assessing a newborn while the new parents watch. The nurse uses an ophthalmoscope to examine the back of the eye (the retina) and notes a positive red reflex. The nurse would explain to the parents that the red reflex indicates:

1. The absence of congenital cataracts.
2. The presence of intraocular hemorrhage.
3. The optic nerve has been traumatized during delivery.
4. Presence of amblyopia.

Correct Answer: 1

Rationale 1: The light of the ophthalmoscope is reflecting off the retina producing the red reflex. This indicates there is nothing preventing the transfer of light.

Rationale 2: The red reflex is a normal finding.

Rationale 3: The optic nerve is behind the retina and not visible.

Rationale 4: Amblyopia cannot be diagnosed at this time and is not evaluated with an ophthalmoscope.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 20

Type: MCMA

The nurse is assessing a new admission to the newborn nursery. Which physical findings suggest the infant was preterm?

Standard Text: Select all that apply.

1. The ear pinna quickly returns to original position after being bent manually.
2. The infant’s resting position is tightly flexed.
3. Labia widely separated with clitoris prominent.
4. Breast area barely perceptible with flat areola, no bud.
5. Sole creases do not extend the length of the foot.

Correct Answer: 3,4,5

Rationale 1: This finding is associated with fetal maturity.

Rationale 2: This finding is associated with fetal maturity. A preterm infant will rest with arms and legs extended.

Rationale 3: In the mature infant, the labia covers the perineal area, including the clitoris.

Rationale 4: This is an indication of immaturity associated with the preterm infant.

Rationale 5: This is an indication of a preterm infant.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-4

Ball, Child Health Nursing, 3/E
Chapter 17

Question 1

Type: MCSA

The nurse is caring for an eight-year-old child who has been in a car accident, has a head injury, and is in the ICU. The nurse sees the child pulling on the IV line. What action should the nurse take?

1. Sedate the child as needed.
2. Place soft wrist restraints on the child.
3. Ask the parents to watch the child closely at all times.
4. Tell the child not to pull on the IV line.

Correct Answer: 2

Rationale 1: Due to the head injury, it is not feasible to sedate the child.

Rationale 2: Children may interfere with treatment by pulling or removing medical devices; soft restraints may be necessary to prevent them from pulling on or removing medical devices.

Rationale 3: It is not feasible for the parents to watch the child at all times.

Rationale 4: The child may not understand what the nurse is trying to convey.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5

Question 2

Type: MCMA

The nurse is taking care of a school-age child with 50% burns to the head and upper part of the body. The nurse recognizes that the most significant stressors for school-age children with life-threatening illness are:

Standard Text: Select all that apply.

1. Painful and invasive procedures.
2. Fear of the medical team.
3. Disfigurement.
4. Separation from family.
5. Loss of self-control.

Correct Answer: 1,3,4,5

Rationale 1: Fear of painful and invasive procedures will cause stress for children.

Rationale 2: School-age children do not usually have a fear of the medical team.

Rationale 3: One stressor for children is fear of disfigurement.

Rationale 4: Although school-age children can separate from their parents, children will find the separation a stressor when the acuity of their illness increases.

Rationale 5: Children who are hospitalized fear losing control of self.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2

Question 3

Type: MCSA

The nurse is preparing a seriously ill child for a procedure. Which age group of children benefits most from being talked to, soothed, and touched during and after the procedure?

1. Preschoolers
2. School-age children
3. Adolescents
4. Toddlers

Correct Answer: 4

Rationale 1: Provide preschool children with an explanation of the sensations they can expect to experience.

Rationale 2: School-age children and adolescents want an explanation of the sensations they can expect.

Rationale 3: Provide adolescents with an explanation of the sensations they can expect to experience (temperature, vibrations, sounds, smells, tastes, sight).

Rationale 4: Toddlers will benefit from being talked to, soothed, and touched during and after the procedure.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-5

Question 4

Type: MCSA

An adolescent with cystic fibrosis is intubated with an endotracheal tube. Which is the most appropriate nursing diagnosis for the adolescent?

1. Impaired social interaction related to hospitalization and separation from peers
2. Delayed growth and development related to prolonged hospitalization and life-threatening condition
3. Powerlessness (moderate) related to inability to speak to or communicate
4. Potential for imbalanced nutrition, more than body requirements related to inactivity

Correct Answer: 3

Rationale 1: Although the adolescent will have difficulty with social interaction, that is not the primary concern at this time.

Rationale 2: There may be issues related to growth and development, but they are not the primary concerns at this time.

Rationale 3: The adolescent values communication and might feel frustrated that he cannot speak and make his wishes known while intubated.

Rationale 4: The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17-5

Question 5

Type: MCSA

A 16-year-old boy has a stiff neck, a headache, a fever of 103° Fahrenheit, and purpuric lesions on his legs. He is admitted to the hospital for treatment of suspected meningococcemia. Although the adolescent’s physical needs take priority at the present time, the nurse can expect which of the following to be the most significant psychological stressor for this adolescent?

1. Fear of getting behind in schoolwork
2. Fear of painful procedures and bodily mutilation
3. Separation from friends and permanent changes in appearance
4. Separation from parents and home

Correct Answer: 3

Rationale 1: School-age children are developing a sense of industry and fear getting behind in schoolwork.

Rationale 2: Preschoolers fear pain and bodily mutilation.

Rationale 3: Adolescents are concerned about their appearance and how they look compared with their peers. Adolescents are developing their identities and rely most on their friends.

Rationale 4: Separation from parents and home is the main psychological stressor for infants and toddlers.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2

Question 6

Type: MCSA

A six-year-old child is in the pediatric intensive care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway, and he collided with a car. The parents appear lost and unable to take in the medical discussion. Which nursing diagnosis is most appropriate for the parents of this child?

1. Parental role conflict related to child’s wellness vs. illness
2. Guilt related to buying a bicycle for the child
3. Family coping: compromised, related to the critical injury of the child
4. Knowledge deficit home care of fractured femur

Correct Answer: 3

Rationale 1: At this point, the parents will not be conflicted or confused whether they want their child well or ill.

Rationale 2: The parents may experience guilt for purchasing a bicycle and not providing a helmet for the child, but the parents’ behavior does not suggest this diagnosis at this time.

Rationale 3: The parents are displaying ineffective coping behaviors. The parents might be experiencing hopelessness, frustration, and anxiety, and they are not coping well as a family unit.

Rationale 4: During the initial phase of the accident, the family is not focusing on discharge planning and care of the fractured femur.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17-4

Question 7

Type: MCMA

In caring for a child with a life-threatening illness, the nurse should anticipate the parent’s reaction to the child illness. Which response should the nurse anticipate the parent will experience?

Standard Text: Select all that apply.

1. Anticipatory waiting
2. Post-traumatic stress disorder
3. Deprivation and loss
4. Anger and guilt
5. Readjustment and mourning

Correct Answer: 1,3,4,5

Rationale 1: Once the child’s condition is stabilized and survival seems likely, parents often move into a period of anticipatory waiting.

Rationale 2: Children may develop posttraumatic stress disorder following a life-threatening injury. It is not a reaction of the parents.

Rationale 3: As the shock associated with the child’s life-threatening condition slowly recedes, new stressors emerge. Parents are deprived of their familiar role of being a parent of a healthy child.

Rationale 4: Anger and guilt surface as parents become more aware of their child’s illness or injury.

Rationale 5: The last stage that parents experience is readjustment or mourning.Readjustment is experienced as the child recovers.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-4

Question 8

Type: MCMA

A child is admitted to the PICU following an accident. The parents ask the nurse about bringing the siblings to visit. The nurse will meet with the siblings and the parents and:

Standard Text: Select all that apply.

1. Describe the sights, sounds, and smells of the pediatric intensive care unit.
2. Provide a simple explanation of the other children being cared for in the PICU.
3. Explain the child’s injuries in ways that are appropriate to the ages of the siblings.
4. Describe how the child looks.
5. Explain why the siblings will not be able to visit until the child has stabilized and is progressing.

Correct Answer: 1,3,4

Rationale 1: Describe the hospital environment, including equipment, sounds, and smells.

Rationale 2: The siblings should not hear about other patients and the other patients should be screened from view of any visitors.

Rationale 3: Using a doll, drawing pictures, or showing an actual picture of the child can help prepare the siblings.

Rationale 4: Before the visit, talk with the siblings about what to expect, and describe how their sibling will look.

Rationale 5: Siblings should be allowed to visit. Such a visit should be encouraged whether the child is improving or deteriorating.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-4

Question 9

Type: MCSA

A newborn is admitted to the neonatal intensive care unit (NICU). The parents are concerned because they cannot stay for long hours to visit. Which statement made by the nurse is most appropriate?

1. “Why can’t you visit after work every day?”
2. “One of you could take a leave of absence to be here more.”
3. “Perhaps the grandparents can make the visits for you.”
4. “Parents often feel this way; you can call any time to see how your baby is doing.”

Correct Answer: 4

Rationale 1: This statement does not focus on how the parents feel and may increase their feelings of guilt.

Rationale 2: This statement does not focus on how the parents feel and attempts to solve the issue rather than allow for the parents to deal with their feelings and form solutions. It may add to feelings of inadequacy.

Rationale 3: While grandparents visiting may increase their comfort about their baby, it will not reduce the parents’ feelings of guilt.

Rationale 4: This statement is therapeutic; it focuses on feelings and offers support to the parents.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5

Question 10

Type: MCMA

In which settings is the nurse most likely to work with parents experiencing shock and disbelief related to the sudden onset of a life-threatening illness for their child?

Standard Text: Select all that apply.

1. Emergency departments
2. Pediatric Intensive Care Unit
3. Operating room
4. Neonatal Intensive Care Unit
5. Pediatric cancer clinics

Correct Answer: 1,2,4

Rationale 1: Sudden onset of life-threatening conditions of children may occur in the emergency department.

Rationale 2: Children admitted to the PICU often face the sudden onset of life-threatening illnesses.

Rationale 3: Although the operating room can have sudden onset of life-threatening conditions, the parents are not in the operating room.

Rationale 4: The condition of infants in the NICU can deteriorate suddenly, and the parents may respond with shock and disbelief.

Rationale 5: Many children attending the pediatric cancer clinics have life-threatening illnesses, but the onset is not sudden and the parents at the clinic will not typically be expressing shock and disbelief.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-1

Question 11

Type: MCSA

A new pediatric hospital is under development. A suggestion that has been shown to improve the psychological comfort of children in the Pediatric Intensive Care Unit would be:

1. Limiting the number of visitors to allow the child to rest.
2. Allowing the parents to visit every two hours for 10 to 15 minutes.
3. Planning all rooms to be two-patient rooms so each child will have another child for comfort and support.
4. Providing a bed for a parent to stay with the child in the PICU.

Correct Answer: 4

Rationale 1: Family members provide emotional support for the child. Limiting visitors will not provide comfort.

Rationale 2: Limiting parents’ visits will not provide emotional support to the children.

Rationale 3: Sick children look to their parents for support and comfort, not to other children.

Rationale 4: Studies have shown that allowing the parents to stay full time with the children has been shown to increase comfort and support for the child and the parent.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-5

Question 12

Type: MCSA

A premature infant is admitted to the Neonatal Intensive Care Unit. The infant is in critical condition, and the outcome is questionable. Nursing behaviors that will promote visitation include:

1. Explaining to the parents that everything possible is being done for their infant.
2. Smiling at the parents and making them welcome when they come to visit.
3. Allowing alone time with their infant when they visit.
4. Introducing the parents to the other parents visiting their babies.

Correct Answer: 2

Rationale 1: This reassurance will not increase parental visits.

Rationale 2: When parents feel they are not “strangers” in the unit, they will be more likely to visit.

Rationale 3: Avoidance of the parents will not make the parents want to visit more often.

Rationale 4: It is appropriate to encourage parents to meet other parents, but this will not increase the parents’ willingness to visit.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5

Question 13

Type: MCSA

Twenty-four hours after being transferred from the pediatric intensive care unit to the regular pediatrics floor, the seven-year-old child is asked about his experience in the PICU. The child says he was not in the PICU but came directly to the floor from the ambulance ride. The nurse recognizes this is a coping behavior for the child known as:

1. Repression.
2. Regression.
3. Amnesia.
4. Developmental delay.

Correct Answer: 1

Rationale 1: Repression is the involuntary forgetting of an experience due to the stress of the situation.

Rationale 2: Regression is a return to earlier behaviors, such as loss of continence or asking for a bottle in a toddler.

Rationale 3: Amnesia is the loss of memory that can result from a head injury. There is no indication of a head injury occurring in this child.

Rationale 4: Developmental delay refers to a child whose behavior is not appropriate for the chronologic age of the child.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-2

Question 14

Type: MCSA

Following a tornado destroying the family home and injuring all family members, the four-year-old child is admitted to the Pediatric Intensive Care Unit. All other family members are hospitalized at a different hospital. The nursing staff can provide the four-year-old with a sense of security by:

1. Providing new toys for the child.
2. Asking a hospital volunteer to visit the child daily and stay as long as possible.
3. Explaining to the child that mom and dad also are sick and cannot come to visit.
4. Keeping the child’s security blanket with the child at all times.

Correct Answer: 4

Rationale 1: Toys are beneficial to normalizing the situation but will not provide as much comfort as the parents’ presence.

Rationale 2: Stability of the people around the child will add to the comfort but is not the best response.

Rationale 3: The child is too young to grasp the situation.

Rationale 4: A security blanket or teddy bear from home will provide the most comfort to the child.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-3

Question 15

Type: MCSA

A baby is born at 32 weeks’ gestation and is admitted to the NICU. After 4 difficult weeks, the child’s condition has improved and survival seems guaranteed. The mother comes every day to feed the infant. Between feedings, the mother sits alone in the waiting room. The mother tells the nurse that she feels her life is in a holding pattern, not yet being a parent but no longer anticipating the excitement of the planned delivery. The nurse recognizes that the mother’s reaction could be defined as:

1. Shock and disbelief.
2. Anticipatory waiting.
3. Readjustment.
4. Mourning.

Correct Answer: 2

Rationale 1: This behavior does not describe shock and disbelief.

Rationale 2: The mother is describing the reaction period often described as anticipatory waiting. She cannot get on with her life until the child’s condition improves and the child is discharged from the NICU.

Rationale 3: Readjustment occurs when the child’s condition has improved to the point of transfer or discharge. When this occurs, the mother will not be “waiting,” but she will be looking forward to starting life with the new baby.

Rationale 4: When the child’s condition deteriorates, the mother would display symptoms of grief.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-3

Question 16

Type: MCSA

A young child is admitted to the hospital following a serious injury while on a field trip with his school class. When the parents arrive at the emergency room, the nurse recognizes that the parents have only limited English. The nurse will:

1. Speak slowly and clearly so the parents can understand.
2. Have a translator/interpreter present when the nurse and physician describe the child’s condition to the parents.
3. Have a family member who speaks English translate for the family
4. Give the parents a pamphlet written in their primary language that describes the hospital routine.

Correct Answer: 2

Rationale 1: The parents will not understand, not because they can’t hear, but because they speak little English. Speaking more clearly will not be very helpful.

Rationale 2: Even if the parents have some English, the stress of the situation may impair communication without a translator.

Rationale 3: The nurse cannot be sure that the family member is translating accurately. In addition, this could violate HIPAA regulations by sharing information with someone other than the parents without the parents’ full agreement. They cannot agree if they do not understand.

Rationale 4: The pamphlet will not explain what is wrong with their child and therefore is not the best solution.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5

Question 17

Type: MCMA

Complementary activities that may reduce stress for the child and parents in the Pediatric Intensive Care Unit include:

Standard Text: Select all that apply.

1. Prayer.
2. Maintaining silence in the PICU.
3. Maintaining a sterile-appearing hospital room.
4. Music playing softly.
5. Encouraging the parents to read age-appropriate books to the child.

Correct Answer: 1,4,5

Rationale 1: For the family with religious beliefs, prayer can provide comfort and support.

Rationale 2: Absolute silence may make the child feel abandoned and is not a comfort.

Rationale 3: The physical appearance of the PICU can be threatening. A colorful, home-like appearance will decrease stress.

Rationale 4: Music has been shown to reduce stress and slow heart and respiratory rates.

Rationale 5: The child will be comforted by hearing the parent’s voice. The parents will be comforted because they will feel they are doing something to benefit their child.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-5

Question 18

Type: MCMA

The hospital recently changed its policy and now allows families members to be present during resuscitation of their child. The benefits expected from this policy change include:

Standard Text: Select all that apply.

1. Positive patient outcomes increase due to the patient hearing family voices during the resuscitation.
2. Parents are reassured that everything possible is being done.
3. Professional behavior by the healthcare team improves.
4. Parental feelings of helplessness decrease.
5. Grieving and closure are facilitated.

Correct Answer: 2,3,4,5

Rationale 1: No studies have shown that the patient outcome is improved.

Rationale 2: This statement is accurate.

Rationale 3: When the healthcare team is aware that the family is present, their behavior is more professional and appropriate.

Rationale 4: Parents feel that they are involved and not just waiting.

Rationale 5: It increases the sense of reality to be present during unsuccessful resuscitation events.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-4

Question 19

Type: MCSA

A child has been comatose in the PICU for three days. The parents have been at the child’s bedside or in the waiting room the entire time. Which statement by the nurse would be most helpful in promoting the parents to take a break?

1. “You’ve been here three days. It is time for you to go home and take a shower.”
2. “Your child isn’t aware you are here anyway, so why don’t you take a break?”
3. “I’ll be with your child, so go home and get a good nap.”
4. “I know you are concerned and afraid to leave. If you’d like to take a short walk, you can leave me your cell phone number and I’ll call you if there are any changes.”

Correct Answer: 4

Rationale 1: This statement is a negative statement and does not address the parents’ emotional needs.

Rationale 2: The parents need to feel needed. It is also impossible to know whether or not the child is aware of the parents’ presence.

Rationale 3: Whereas it may be a comfort to know the child will not be alone, the parents may be uncomfortable leaving the child for any length of time.

Rationale 4: This answer promises to maintain contact and encourages the parents to leave. It also recognizes the parents’ concerns.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-4

Question 20

Type: MCSA

An adolescent with a gunshot wound presents to the emergency department with his distraught parents. He states that he saw a classmate shoot his teacher and several other students. As a result of the shooting incident, the nurse expects this adolescent to be at risk for which disorder?

1. Conduct disorder
2. Depression
3. Post-traumatic stress disorder
4. School phobia

Correct Answer: 3

Rationale 1: Conduct disorder could possibly occur later.

Rationale 2: Depression could possibly occur later.

Rationale 3: Acute stress, parental stress, and the degree of the psychological trauma exposure are variables predictive of post-traumatic stress disorder (PTSD).

Rationale 4: School phobia could possibly occur later.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17-2

Ball, Child Health Nursing, 3/E
Chapter 19

Question 1

Type: MCSA

While teaching the parents of a newborn about infant care and feeding, the nurse instructs the parents to:

1. Delay supplemental foods until the infant is four to six months old.
2. Begin diluted fruit juice at two months of age, but wait three to five days before trying a new food.
3. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after two months of age.
4. Delay supplemental foods until the infant reaches 15 pounds or greater.

Correct Answer: 1

Rationale 1: Age four to six months is the optimal age to begin supplemental feedings. The infant does not need supplemental foods earlier, and introducing supplemental foods earlier does not promote sleep.

Rationale 2: Fruit juice and rice cereal are not well tolerated by infants at two months of age, as they lack the digestive enzymes to take in and metabolize many food products.

Rationale 3: Fruit juice and rice cereal are not well tolerated by infants at two months of age, as they lack the digestive enzymes to take in and metabolize many food products. Introducing cereal at this stage will not help promote sleep.

Rationale 4: Earlier feeding of nonformula foods, regardless of the infant’s weight, is more likely to cause the development of food allergies.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-1

Question 2

Type: MCSA

A nurse is talking to the mother of an exclusively breastfed, African American infant who is three months old and was born in late fall. The nurse would want to make sure that this child is receiving:

1. Iron
2. Vitamin D
3. Calcium
4. Fluoride

Correct Answer: 2

Rationale 1: An infant’s iron stores are usually adequate until about four to six months of age.

Rationale 2: This infant will have limited exposure to sunlight due to decreased sun exposure in the fall and winter months. The limited sun exposure combined with the infant’s dark skin means the infant may need additional vitamin D.

Rationale 3: The infant should be receiving sufficient amounts of calcium from breast milk.

Rationale 4: Fluoride supplementation, if needed, does not begin until the child is approximately six months old.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-1

Question 3

Type: MCSA

While teaching parents of a newborn about normal growth and development, the nurse informs them that their child’s weight should:

1. Triple by nine months of age.
2. Double by five months of age.
3. Triple by six months of age.
4. Double by one year of age.

Correct Answer: 2

Rationale 1: The normal infant triples his birth weight by one year of age.

Rationale 2: It is expected that the infant would double in weight by five months of age.

Rationale 3: The child should double his birth weight by five months. A child whose weight triples by six months of age has gained weight too rapidly.

Rationale 4: The child should triple his birth weight by one year. This child may not be growing adequately.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-1

Question 4

Type: MCSA

The nurse is teaching the parents of a four-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feedings and not letting the infant go to sleep with the bottle, as this is most likely to increase the incidence of both dental caries and:

1. Aspiration.
2. Otitis media.
3. Malocclusion problems.
4. Sleeping disorders.

Correct Answer: 2

Rationale 1: There have been limited data to date showing a positive correlation to bottle propping and increased risk of aspiration.

Rationale 2: The infant’s Eustachian tube, which connects the throat to the middle ear, is shorter and straighter than an adult’s. When babies lie flat to feed, milk can easily enter the middle ear and increase the risk for otitis media.

Rationale 3: The primary concerns related to bottle propping are dental caries and otitis media. Poor dental alignment is not a significant problem.

Rationale 4: Sleeping disorders have not been found to be related to bottle propping.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-1

Question 5

Type: MCSA

An adolescent who is a vegetarian has been placed on iron supplementation secondary to a diagnosis of iron-deficiency anemia. To increase the absorption of iron, the nurse would instruct the teen to take the supplement with:

1. Orange juice.
2. Black or green tea.
3. Milk.
4. Tomato juice.

Correct Answer: 1

Rationale 1: Acidity increases absorption of iron.

Rationale 2: Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Rationale 3: Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Rationale 4: Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-2

Question 6

Type: MCSA

The nurse is presenting a program on healthy eating habits to the parents of children attending the clinic. In the discussion period of the program, parents make the following comments. Which parent needs more information about safe food preparation?

1. “We always wash our hands well before any food preparation.”
2. “We use separate utensils for preparing raw meat and for preparing fruits, vegetables, and other foods.”
3. “We take the meat out of the freezer and then allow it to thaw on the counter for two to three hours before cooking it thoroughly.”
4. “If our baby doesn’t drink all the formula in his bottle, we throw the rest out.”

Correct Answer: 3

Rationale 1: Washing hands removes pathogens from the hands and prevents food contamination.

Rationale 2: Raw meats are a good source of pathogens. Utensils used on raw meat can transfer the pathogens to other foods if they are not prepared in a manner to destroy these pathogens.

Rationale 3: Allowing meat to sit out on a counter can cause the bacteria counts to increase quickly, and cooking the meat might not effectively destroy all of the bacteria. Frozen meat should be thawed in the refrigerator prior to cooking.

Rationale 4: While drinking from a bottle, organisms can be transferred from the baby’s mouth to the formula. If this formula is saved, the organisms can multiply in the formula.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-4

Question 7

Type: MCSA

During a four-month-old infant’s well-child checkup, the nurse discusses introduction of solid foods into the infant’s diet. Although the nurse recommends delaying the introduction of many foods into the diet, which food(s) will the nurse discuss delaying because they increase the risk for food allergy?

1. Honey
2. Carrots, beets, and spinach
3. Pork
4. Cow’s milk, eggs, and peanuts

Correct Answer: 4

Rationale 1: Although honey can contain botulism spores that cannot be detoxified by the infant younger than one year old, it does not cause an allergic reaction.

Rationale 2: Carrots, beets, and spinach contain nitrates and should not be given before four months of age.

Rationale 3: The addition of pork is delayed until the infant is 8 to 10 months because meats are hard to digest.

Rationale 4: Cow’s milk, eggs, and peanuts are foods that have been associated with food allergies.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4

Question 8

Type: MCMA

The parents of a two-and-a-half-year-old are concerned about their child’s finicky eating habits. While counseling the parents, which statements by the nurse would be accurate?

Standard Text: Select all that apply.

1. “Nutritious foods should be made available at all times of the day so that the child is able to ‘graze’ whenever he is hungry.”
2. “The child is experiencing physiologic anorexia, which is normal for this age group.”
3. “A general guideline for food quantity at a meal is one-quarter cup of each food per year of age.”
4. “It is more appropriate to assess a toddler’s nutritional demands over a one-week period rather than a 24-hour one.”
5. “The toddler should drink sixteen to twenty-four ounces of milk daily.”

Correct Answer: 2,4,5

Rationale 1: Food should be offered only at meal and snack times.

Rationale 2: Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age.

Rationale 3: The correct general guideline for food quantity is 1 tablespoon of each food per year of age.

Rationale 4: It is not unusual for toddlers to have food jags where they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day.

Rationale 5: Two to three cups of milk per day are sufficient for a toddler; more than that can decrease his desire for other foods and lead to dietary deficiencies. Children should sit at the table while eating to encourage socialization skills.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4

Question 9

Type: MCSA

A six-year-old recently diagnosed with asthma also has a peanut allergy. The nurse instructs the family not only to avoid peanuts, but also to check food label ingredients carefully for peanut products and to make sure dishes and utensils are adequately washed prior to food preparation. The mother asks why this is specific for her child. The nurse should reply that in comparison with other children, this child has a higher risk for:

1. Urticaria.
2. Anaphylaxis.
3. Diarrhea.
4. Headache.

Correct Answer: 2

Rationale 1: Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Rationale 2: The child who also has asthma is at greatest risk for death secondary to anaphylaxis caused by a food allergy.

Rationale 3: Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Rationale 4: Children with food allergies can experience urticaria, diarrhea, and headaches when exposed to a particular food.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Question 10

Type: MCSA

During a well-child physical, a 16-year-old girl has a normal history and physical except for an excessive amount of tooth enamel erosion, a greater-than-normal number of filled cavities, and calluses on the back of her hand. Her body mass index is in the 25th to 50th percentile for her age. Based on these findings, which disorder would the nurse suspect?

1. Anorexia nervosa
2. Bulimia nervosa
3. Marasmus
4. Kwashiorkor

Correct Answer: 2

Rationale 1: Anorexia nervosa is an eating disorder where individuals literally starve themselves to prevent weight gain and also exercise excessively and use laxatives and diuretics to lose weight. Anorexia usually manifests as extreme weight loss and an obsession with food.

Rationale 2: The erosion of the tooth enamel and the presence of dental caries and calluses on the back of her hand all most likely are due to frequent vomiting of gastric acids, which is common with this disorder as part of a “binge-purge” cycle.

Rationale 3: Marasmus is a lack of energy-producing calories that can be seen in anorexia; it causes emaciation, decreased energy levels, and retarded development.

Rationale 4: Kwashiorkor is a protein deficiency, usually from malnutrition, that manifests as generalized edema.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-5

Question 11

Type: MCSA

A six-year-old child has been newly diagnosed with cystic fibrosis. During discharge teaching, the nurse is instructing the parents on nutritional requirements specifically related to the child’s decreased ability to absorb fats. The nurse teaches the family that the child will need supplementation with vitamins that are fat soluble, such as:

1. Vitamin K.
2. Riboflavin.
3. Vitamin B_12.
4. Thiamin.

Correct Answer: 1

Rationale 1: Vitamin K is fat soluble, as are A, D, and E.

Rationale 2: Riboflavin, vitamin B₁₂, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Rationale 3: Riboflavin, vitamin B₁₂, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Rationale 4: Riboflavin, vitamin B₁₂, and thiamin are all water-soluble vitamins, and their absorption is not related to availability of dietary fat.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Question 12

Type: MCMA

The mother of a six-week-old infant tells the nurse that her baby has had colic for several days, crying for up to three hours and drawing his legs up on his abdomen. The mother says she is at “wits end” and wonders what she can do. The nurse learns that the infant is formula fed and gaining weight satisfactorily. The nurse would recommend:

Standard Text: Select all that apply.

1. Breastfeeding the infant.
2. Switching to a bottle that has a collapsible bag inside.
3. Putting the infant in a baby swing after feeding.
4. Burping the baby more frequently.
5. Giving the baby a suppository once each morning.

Correct Answer: 2,3,4

Rationale 1: The infant is six weeks old. Initiating breastfeeding is not a good option at this time.

Rationale 2: This would reduce the amount of air that the baby swallows.

Rationale 3: The motion may reduce the abdominal discomfort.

Rationale 4: This helps the infant expel gas, which is a factor contributing to colic.

Rationale 5: Suppositories would not be recommended.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-2

Question 13

Type: MCSA

A 14-year-old girl is being admitted to the eating disorders unit of the hospital. The girl has a two-year history of anorexia nervosa and recently has sustained additional weight loss and electrolyte imbalances. During hospitalization, the priority concern for the health care team will be:

1. Individual counseling.
2. Family therapy.
3. Regulation of antidepressant drugs.
4. Nutritional support.

Correct Answer: 4

Rationale 1: This will be an important component of inpatient treatment but is not the priority intervention.

Rationale 2: Family therapy is usually a component of the treatment of anorexia nervosa but is not the priority intervention.

Rationale 3: Antidepressant drugs may be used as a component of the treatment, but this is not the priority intervention.

Rationale 4: Hospitalization usually is in response to the weight loss and electrolyte imbalances, so nutritional support becomes the priority intervention. All other activities can be managed as outpatient therapies.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-6

Question 14

Type: MCMA

A two-month-old infant is admitted to the hospital with a diagnosis of “failure to thrive” (FTT). The nurse recognizes that the infant will be evaluated for:

Standard Text: Select all that apply.

1. Over-dilution of formula concentrate.
2. Parental neglect.
3. Rumination.
4. Malabsorption syndromes.
5. Pica

Correct Answer: 1,2,3,4

Rationale 1: Adding too much water to formula concentrate will lead to inadequate caloric intake and could lead to a diagnosis of FTT.

Rationale 2: Parental neglect should be evaluated in a baby that is not gaining weight adequately.

Rationale 3: Rumination involves regurgitation of recently ingested food followed by re-chewing and re-swallowing. It is often associated with sensory deprivation and may result in growth failure.

Rationale 4: Malabsorption syndromes, such as cystic fibrosis, can cause nutrients to be excreted instead of absorbed.

Rationale 5: Pica is an eating disorder characterized by ingestion of nonfood items. It would not be an issue in a two-month-old infant.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-4

Question 15

Type: MCMA

A two-year-old child is admitted to the hospital for chronic diarrhea. After investigation, the child is diagnosed with celiac disease. The nurse teaches the family to avoid all glutens and to carefully read all labels. In evaluating the parents’ understanding, the nurse allows the family to complete the child’s menus. The nurse recognizes the family understands glutens when they choose which foods?

Standard Text: Select all that apply.

1. Milk
2. Mashed potatoes with gravy
3. Apple sauce
4. Corn in cream sauce
5. Rice cakes

Correct Answer: 1,3

Rationale 1: Milk is a protein and contains no glutens.

Rationale 2: Gravy is made with flour. Unless the parents know the source of the flour, gravy should be avoided. Most types of gravy contain wheat.

Rationale 3: All fruits are gluten free.

Rationale 4: Corn is acceptable. Cream sauce will probably have a vegetable protein as a filler.

Rationale 5: There are some brands of rice cakes that are gluten-free, but without reading the label, these should be avoided.

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Question 16

Type: FIB

A premature infant is being tube fed. The physician ordered the feeding to total 120 kcal/kg/day. The infant weighs 1.86 kg. The formula contains 20 kcal per ounce. How many ounces of formula should the infant receive per day? Round your answer to the hundredth.

Standard Text:

Correct Answer: 11.16

Rationale : 1.86 kg ×120 kcal/day = 223.2 kcal/day. 223.2 kcal divided by 20 kcal/ounce = 11.16 ounces

Global Rationale:

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5