How can we help?

You can also find more resources in our Help Center.

NUR320 - Exam 1 Study Guide - Part II

textbook supplementals from textbook and mynursingkit.com
STUDY
PLAY
Chapter 1: Nurse's Role in Care of the Child: Hospital, Community Settings, and Home
...
■ Roles of nurses in caring for children include providing direct care (health promotion, health maintenance, and nursing care for health conditions), patient education, patient advocacy, and case management, and minimizing the psychological and physical distress experienced by children and their families.
...
■ Nurses care for children in many different settings: various units within the hospital and outpatient clinics, schools, childcare centers, physician offices, community health centers, rehabilitation centers, and the home.
...
■ Family-centered care is a method designed to meet the emotional, social, and developmental needs of children and families needing health care.
...
■ Nurses must identify culturally relevant facts about their patients to provide appropriate and competent care to an increasingly diverse population.
...
■ Unintentional injury is the leading cause of death for children between 1 and 1 9 years of age.
...
■ Efforts to increase the number of children with access to health care include the State Children's Health Insurance Program (SCHIP) currently being implemented nationwide.
...
■ Documentation of nursing care is essential for risk management and quality improvement. Documentation must include the patient assessment, the nursing care plan, the child's responses to medical therapies and nursing care, and the regular evaluation of the child's progress toward nursing goals.
...
■ Informed consent is the formal preauthorization for an invasive procedure or participation in research. Parents typically give informed consent for children under 18 years of age unless the child is an emancipated minor, a self-supporting adolescent not subject to parental control.
...
■ Children need to become more actively involved in decisions about their care as their decision-making abilities develop. Even though they cannot provide informed consent, federal guidelines mandate that children as young as 7 years of age receive information about treatment procedures and research project participation and give their assent.
...
■ Because adolescents fear disclosure of confidential information, they may avoid seeking health care. When adolescents have a reportable disease, it is important to inform them that confidentiality cannot be maintained, as a report must be made to a public health agency.
...
■ Adolescents at a higher risk of death due to a serious acute or chronic condition should be encouraged to talk with their parents and jointly prepare advance directives.
...
■ Federal regulations require a formalized ethical decision making process to assist healthcare providers and families in making important decisions about witholding, withdrawing, or limiting a child's therapy.
...
CRITICAL THINKING IN ACTION:
Drew Santo is a 3-year-old boy who has a seizure disorder that until a week ago was fairly well controlled by medication. He and his family receive health care at the center serviced by their health plan. A pediatric nurse and pediatrician collaborate in providing Drew's health care and monitoring his developmental progress. Drew had a seizure in the last week. His phenytoin blood level, taken the day of the seizure, was slightly lower than the therapeutic range. This likely indicates that his parents have given Drew his medication fairly regularly, but perhaps he needs a higher dosage or a different medication. Because of the recent seizure, an electroencephalogram (EEG) is ordered to identify any change in the electrical pattern in the brain. Other laboratory tests are also ordered, following the guidelines of the health center's clinical pathway for children with seizure disorders. Over the past 2 years, Drew's family and the pediatric nurse have worked in partnership to ensure that Drew is treated as a healthy child with a chronic condition. The nurse has helped his parents to obtain information about his condition, to understand the action of his medication, and to take appropriate measures when he has a seizure. Drew's parents are upset that he has again had a seizure, especially when they have done everything they could to keep the seizures under control. They have been able to think of him as a normal boy because he had not had a seizure for a long time. Now they wonder if they will be able to keep treating him that way. In how many different settings could you find nurses providing care to children with this condition? Does the type of nursing care provided to children differ among these settings?
...
INTRODUCTION:
Return to the scenario about Drew at the beginning of the chapter. Despite his seizure disorder Drew has been developing normally, meeting expected developmental milestones as evaluated by the Denver II (see Chapter 11).
...
DESCRIPTION:
The pediatric nurse has worked closely with the family to ensure that all of Drew's healthcare needs are addressed during health promotion and health maintenance visits. Prior to the seizure, the nurse had been helping the parents to ensure that all healthcare requirements were met for Drew to attend a new childcare center. The pediatric nurse will now modify the nursing care plan to integrate the needed diagnostic procedures and treatment for Drew's seizure disorder, and to help the parents manage their increased concerns about his seizure disorder.
...
DISCUSSION
1 . Identify all the roles of Drew's nurse in working with this child and his family. What other roles could nurses have within this healthcare center and in other settings to support the nursing care provided to Drew and his family? Consider the roles of a nurse manager in the healthcare setting, a nurse consultant to the childcare center, and a nurse in the emergency department.
The roles for the nurse are direct care provider, advocate, educator and case manager. The nurse is a liaison to other personnel in the preschool and any other activity in which the child participates. The nurse consultant would partner with the health care provider and family to assess, plan, implement and evaluate emergency care plans in the preschool. This plan may also include safe delegation of health care in the community setting. The emergency room nurse participates in evidence based practice for emergency treatment of seizures. Any nurse will be participating in research activities that may direct the care of children with seizures.
2. Informed consent is often needed before diagnostic procedures are performed and prior to releasing healthcare information. What is the process for obtaining informed consent in your healthcare setting? What is the nurse's role in the process? What needs to happen before health information is released to the childcare center? How does this healthcare facility ensure compliance with HIPAA?
The first step in obtaining informed consent is to determine who has legal responsibility for the child. This may be done in partnership with social services. Prior to the procedure, the person performing the procedure will obtain the consent. The nurse is often the witness. The nurse will also be the person who is available for additional explanation if the parents/guardians need it. The nurse is responsible to assure that the proper consent is in place before the procedure is performed. A release of information signed by the parent/guardian is required before releasing information to the child care center. The child care center OR the health care provider may initiate the release of information. HIPAA regulations are posted and families sign a statement that they understand their rights. Physical privacy barriers are in place.
3. The healthcare setting where Drew receives care has an evidence-based clinical pathway for the management of children with seizures. Identify a clinical pathway that has been developed for a pediatric healthcare condition in your healthcare setting. How is the clinical pathway used and how does this process differ from implementation of a nursing care plan?
An example of a clinical pathway would be for children with asthma in the hospital setting. The pathway is utilized by all care providers from the emergency department and the inpatient units. It dictates all aspects of care from an interdisciplinary standpoint. The plan includes medical interventions, diagnostic tests, comfort measures, family centered care, goals and outcomes, and discharge parameters. It differs form a nursing care plan because it is developed and implemented by ALL health care team members. The nursing care plan is specifically individualized for the child and family, whereas the clinical pathway is a general population guideline.
4. Describe the nursing interventions for the modified nursing care plan for diagnostic procedures, treatment, and family concerns.
Nursing interventions for the modified care plan include:
Preparation for the child for the indicated tests, educating family and child with developmental appropriate methods, offering support for family concerns and linking family with available resources as needed.
accommodation
The process of changing an individual's cognitive structures to include data from recent experiences.
adherence
The extent to which a patient or parent acts consistently with regard to recommended care.
advance directives
A patient's living will or appointed durable power of attorney for healthcare decisions.
Advocacy
Acting to safeguard and advance the interests of another.
Assent
Voluntary agreement to participate in a research project or to accept treatment.
autonomy
Right for self-determination in decision making or to protect the informed choices of patients who are capable of decision making.
Beneficence
An obligation to act or make a decision to benefit the patient.
Case management
A process of coordinating the delivery of healthcare services in a manner that focuses on both quality and cost outcomes.
Clinical pathways (critical pathways)
Structured care plans for a specific patient problem that outline patient goals and essential steps in the management of a child by multiple healthcare professionals within a healthcare facility.
Clinical practice guidelines
Specific medical and nursing assessments and interventions that occur during specific time intervals for a specific condition; often adopted by an institution for all healthcare providers to follow so that quality of care is increased and costs of care are minimized.
competence
An ability to be involved in healthcare decisions requiring a certain degree of intellect, an ability to communicate, and an ability to remember.
Confidentiality
An agreement between a patient and a provider that information discussed during the healthcare encounter will not be shared without the permission of the patient.
continuity of care
An interdisciplinary process of facilitating a patient's transition between and among settings based on changing needs and available resources.
Critical thinking
An individualized, creative thinking or reasoning process that the nurse uses to solve problems.
emancipated minors
Self-supporting adolescents under 18 years of age not subject to parental control.
Ethics
The philosophic study of morality, and the analysis of moral problems and moral judgments.
Evidence-based practice
Integration of the best research evidence with an individual's clinical expertise and the patient's values or preferences.
Family-centered care
A partnership between families, the nurse, and other health professionals in which the priorities and needs of the family are addressed when the family seeks health care; a dynamic, deliberate approach to building collaborative relationships between health professionals and families that are respectful of diversity and beliefs about the nature of the child's condition and ways to manage it.
Health literacy
The degree to which individuals have the capacity to obtain and understand basic health information needed to make appropriate health decisions.
healthcare home
A continuous, comprehensive, family-centered, and compassionate source of health care. Also known as a medical home.
Informed consent
A formal preauthorization for an invasive procedure or participation in research.
Justice
Fairness in the use of resources.
Managed care
A health delivery system that combines financing and delivery of specified healthcare services with the following elements in place: clinicians are contracted to provide services for a preset fee, clinicians are selected according to specific standards, formal programs of quality assurance and utilization review are in place, and members of the health program have incentives to use selected clinicians.
Mature minors
Adolescents of 14 and 15 years of age who are able to understand treatment risks and who, in some states, can consent to or refuse treatment.
Medical futility
The treatment of an irreversibly dying patient that provides no physiologic benefit to the patient.
medical home
A continuous, comprehensive, family-centered, and compassionate source of health care. Also known as a healthcare home.
moral dilemma
A conflict of social values and ethical principles that support different courses of action.
morbidity
An illness or injury that limits activity, requites medical attention or hospitalization, or results in a chronic condition.
Nonmaleficence
To prevent harm.
partnership
A relationship in which participants join together to ensure healthcare delivery in a way that recognizes the critical role and contribution of each partner in promoting health, preventing illness, and managing healthcare conditions.
privacy
Ability of an individual to relate information in a protected manner.
Quality improvement
The continuous study and improvement of the processes and outcomes of providing healthcare services to meet the needs of patients by examining the system and processes of care and service delivery.
Risk management
A process established by a healthcare institution to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors, and thereby reduce the institution's liability.
1 . Which is an important difference between general and advanced practice roles in child health nursing?

1 . Only the general practice nurse can act as a patient advocate.
2. Only the general practice nurse can educate patients and families.
3. Only the advanced practice nurse can act as a case manager.
4. Only the advanced practice nurse can manage medications.
4. Only the advanced practice nurse can manage medications.

Rationale: Both the advanced and general practice nurse are responsible for functioning as a client advocate, can act as a case manager, and can educate clients and families. However, only an advanced practice nurse can manage client medications. Cognitive Level: Application; Client Need: Safe, Effective Care Environment; Nursing Process: Implementation; Learning Outcome: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.
2. In which situations are children at risk of injury? Choose all that apply.

1 . An infant is crawling on the floor while older children are playing nearby.
2. An adolescent is learning how to become a safe babysitter.
3. A toddler is playing on the playground while at preschool.
4. A school-age child likes to imitate her older sibling's movements while on her bike.
5. An adolescent is attending a gathering of school friends after a dance.
1 . An infant is crawling on the floor while older children are playing nearby.
3. A toddler is playing on the playground while at preschool.
4. A school-age child likes to imitate her older sibling's movements while on her bike.
5. An adolescent is attending a gathering of school friends after a dance.

Rationale: In all but one ofthese situations, there is the possibility of the child getting hurt. The infant may put small parts ofthe toys in his/her mouth; the toddler may fall while on the playground; the school-age child may not physically be capable ofsafely doing the same movements as her older sibling; and adolescents are more likely to do activities as a result ofpeer pressure, when other adolescents are around. The safe babysitter class poses no immediate threat to the adolescent's safety. Cognitive Level: Comprehension; Client Need: Physiologic Integrity; Nursing Process: Assessment; Learning Outcome: Analyze the current causes of child morbidity and mortality and identify opportunities for nurses to intervene.
3. In planning an educational session for parents of toddlers concentrating on primary prevention, which indicates the most appropriate topic on which the nurse should concentrate?

1 . Unintentional injury prevention
2. Seizure management
3. Child abuse prevention
4. Sudden infant death prevention
1. Unintentional injury prevention

Rationale: Toddlers ages 1 to 4 are most likely to be hospitalized or killed from unintentional injury. Therefore, the nurse should concentrate on this topic for these parents. Seizure management is not primary prevention, and although child abuse can occur in this age group, injuries occur more frequently. SIDS does not occur in this age group. Cognitive Level: Analysis; Client Need: Physiological Integrity; Nursing Process: Planning; Learning Outcome: Analyze the current causes ofchild morbidity and mortality and identify opportunities for nurses to intervene.
4. A child and his grandfather arrive in the emergency department after a car collision. The grandfather does not have custody of the child. What should be the nurse's next action?

1 . Obtain the custodial parent's telephone number for permission.
2. Provide emergency care to both under implied consent.
3. Register and provide care to the grandfather but transfer the child.
4. Ensure permission to treat is obtained prior to registering them.
1. Obtain the custodial parent's telephone number for permission.

Rationale: No indication is given regarding the nature of the injuries for either the grandfather or the child. Therefore, permission to treat should be obtained from the custodial parent. Implied consent only applies in life or death situations and there is no indication ofthis in the stem. Registration can occur while permission to treat is obtained, and transferring cannot occur until the child has a medical screening exam. Cognitive Level: Application; Client Need: Physiological Integrity; Nursing Process: Implementation; Learning Outcome: Contrast the policies for obtaining informed consent of minors with policies for adults.
1. Which role would the nurse be serving when helping parents understand and respond to the needs of an ill child's siblings?

1. Advocate
2. Researcher
3. Educator
4. Case manager
1. Advocate

Rationale: The nurse acts to safeguard the child's interests by educating and supporting his parents; therefore, advocate is correct. A team effort is not being coordinated as it relates to the child's needs, so case manager is incorrect. The nurse is, in fact, educating the child's parents. The education is focused specifically on advocacy in relation to the child's needs, so educator also is incorrect. Though the nurse would certainly want to provide evidence-based care to the family, the role in this instance is that of an advocate for the child, not a researcher.
2. In planning care for a student with a seizure disorder, the school nurse considers that this child's educational rights are protected by which most recent federal legislation?

1. Title V
2. Healthy Start
3. The Individual with Disabilities Education Act
4. Sheppard-Towner Act
3. The Individual with Disabilities Education Act

Rationale: The Individual with Disabilities Education Act was designed to ensure that all children have access to appropriate education in the least restrictive environment. The other choices are not the most recent. Review IDEA 1997.
3. Prior to identifying a nursing diagnosis for a 3-year-old child with seizure disorder, it is important that the nurse:

1. Define nursing intervention classifications (NICs) relevant to his care.
2. Carry out interventions specified in the nursing care plan for him.
3. Synthesize data to make a judgment about the child's problems.
4. Use both objective and subjective measures to assess progress in meeting goals for the child.
3. Synthesize data to make a judgment about the child's problems.

Rationale: It is important to assess prior to making decisions; therefore, synthesizing data to make a judgment about the child's problems is the best answer. Carrying out interventions specified in the nursing care plan for him would be premature; remember that the nurse should assess before any intervention. Defining nursing intervention classifications (NICs) relevant to his care would not be done yet; after assessing, the nurse would examine the NIC database. Using both objective and subjective measures to assess progress in meeting goals for the child also is incorrect. First the nurse would have to define those goals, following a comprehensive assessment.
4. The nurse assigned to care for a 3-year-old child with seizure disorder is unsure of protocols for nursing management of children with seizure disorders. To identify the best evidence to use to provide care, the nurse should consult:

1. Internet search engines.
2. Critical pathways for 3-year-old children.
3. Clinical practice guidelines.
4. Research studies.
3. Clinical practice guidelines.

Rationale: Clinical practice guidelines are most valuable in promoting uniformity and excellence in care. The wealth of both credible and incorrect information on the Internet precludes the use of Internet search engines for best care. A synthesis of the best research is provided in clinical practice guidelines. Individual articles are not sufficient as guides to practice. Because the child is 3 years old, the nurse would need to consult only critical pathways that have as their focus protocols for managing seizures in children. These are found in clinical practice guidelines.
5. The nurse is planning educational interventions to reduce the incidence of the number one cause of mortality in children ages 1 to 4. Recognizing the developmental needs of this age group, the nurse would focus the session on which topic?

1. Child abuse prevention
2. Seizure disorder management
3. Unintentional injury awareness
4. Sudden infant death syndrome (SIDS) recognition
3. Unintentional injury awareness

Rationale: Unintentional injury awareness includes motor vehicle accidents, so teaching should include prevention factors. Although all the other choices are a significant cause of mortality, they are not the number one problem for children ages 1 to 4.
6. The nurse recognizes the need to update knowledge related to the most common cause of hospitalization in children. On which body system should continuing education focus?

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

Rationale: Respiratory diseases are the most common admission to hospitals in children from 1 to 14 years old. They account for 33% of hospital discharges in the 1- to 14-year-old age group.
7. The nurse is caring for a pediatric patient not covered by insurance. Which statement to the child's parents regarding the State Child Health Insurance Program is accurate?

1. Eligibility for coverage is determined based on household income and the number of children.
2. Eligibility for the program is determined based on the child's medical diagnosis.
3. Early application is recommended due to the large number of applications received annually.
4. Families are only eligible if the parents are unemployed.
1. Eligibility for coverage is determined based on household income and the number of children.

Rationale: The State Child Health Insurance Program is designed to provide the patient with health insurance comparable to federal/state employee benefit programs. This program is undersubscribed, with lack of knowledge of its eligibility requirements being one of the barriers to subscription.
8. A 15-year-old is hospitalized following her second relapse of acute myelogenous leukemia and is scheduled for a bone marrow transplant. She tells the nurse that she doesn't want to go through with it and that she would rather die. The nurse should:

1. Ensure that her parents sign the informed consent form.
2. Inform the physician and nursing supervisor.
3. Cancel the procedure.
4. Inform the patient's teacher.
2. Inform the physician and nursing supervisor.

Rationale: The child is of an age where issues of consent need to be considered seriously; therefore, informing the physician and nursing supervisor is the best answer. Telling her teacher of her decision violates patient confidentiality. Canceling the procedure is not under the nursing scope of practice. Ensuring that her parents sign the informed consent form does not address the moral conflict in this situation.

Rationale: The child is of an age where issues of consent need to be considered seriously; therefore, informing the physician and nursing supervisor is the best answer. Telling her teacher of her decision violates patient confidentiality. Canceling the procedure is not under the nursing scope of practice. Ensuring that her parents sign the informed consent form does not address the moral conflict in this situation.
9. An adolescent client states that he would rather die than undergo a prescribed treatment. Which of the following ethical principles should direct the nurse in planning care for this client? (Select all that apply.)

1. Nonmaleficence
2. Compassion
3. Justice
4. Beneficence
5. Autonomy
1. Nonmaleficence
4. Beneficence
5. Autonomy

Rationale: Autonomy, the right to self-determination, and involvement in decision making should be respected in all individuals to the extent of their capacities. Adolescents are able to think abstractly and should have this right respected. Often it is compromised. Beneficence - an obligation to act or to make a decision to benefit the client, promoting the child's well-being in addition to working with parents and other family members - and nonmaleficence, preventing harm, also are appropriate. Justice, or fairness in the use of scarce resources, is another ethical principle important to consider in decision making but is not central to this situation. Compassion is considered a virtue, not an ethical principle.
10.In order to administer a medication safely to a pediatric client, what drug information must the nurse be aware of that is not always essential when administering a medication to an adult client?

1. Recommended dose per kilogram of body weight
2. Indicators of drug toxicity
3. Incompatibilities with other medications
4. Commonly expected side effects
1. Recommended dose per kilogram of body weight

Rationale: Children require medication doses based on weight or body surface area. Consequently, nurses must determine the appropriateness of the ordered dose and be able to calculate its preparation. Drug calculations are very complex and consequently pose a greater risk for error.

Rationale: Children require medication doses based on weight or body surface area. Consequently, nurses must determine the appropriateness of the ordered dose and be able to calculate its preparation. Drug calculations are very complex and consequently pose a greater risk for error.
How would you design the content of a smoking prevention patient education brochure for an immigrant population of parents written at the fifth- to sixth-grade level designed to help them counsel their school-aged children? Ensure that the brochure is both linguistically and culturally appropriate.
The brochure should be written in short words of no more than two syllables when possible with words familiar to the target audience (e.g., urinate might be better referred to as pass water). Medical terms should be expressed with simple language (e.g., pulmonary function might be changed to ease of breathing). The brochure should use short sentences as well with active rather than passive verbs. The words used should be well understood by the audience. Including graphics is a great idea. Make sure that they are correct and clearly labeled.
Now design the content of a smoking prevention patient education brochure for a population of 12-year-old students written at the fifth- to sixth-grade level. The brochure should be written in a way that attends to what is important to the children. Ensure that the writing is both developmentally and culturally appropriate.
The brochure should be written in short words of no more than two syllables when possible with words familiar to the target audience (e.g., urinate might be better referred to as pee with a school-aged population). Medical terms should be expressed with simple language (e.g., pulmonary function might be changed to the way you breathe). The brochure should use short sentences as well with active rather than passive verbs. The words used should be well understood by the audience (e.g., until adolescence, children have difficulty understanding abstract concepts). Including graphics is a great idea. Make sure that they are correct, attractive, and clearly labeled.
A 10-year-old client sustained a deep laceration on her leg from falling on a rusty can. She had lost a significant amount of blood by the time she arrived at the hospital with her parents. Neither the child nor her parents agree to an emergency blood transfusion ordered by the physician.

Think about all the reasons why the parents and child might want to select a different treatment than that proposed by the physician (e.g., cultural, religious, protection of child, etc.), and suggest a course of action that respects the family's autonomy while protecting the child from hypovolemia.
Your answer might include their fear of the transmission of disease through blood products; their past experiences with such treatment; their religious orientation, which might forbid transfusions, believing them to be morally and spiritually sinful; and cultural prohibitions from using blood.
Ethical issues arise from a moral dilemma, a conflict of social values and ethical principles that support different courses of action that could be correct, depending on the individual's values and beliefs. Whereas adults are permitted to refuse blood products (even when death can occur), most healthcare institutions have policies that address the care of children in need of blood products.
A 10-year-old client sustained a deep laceration on her leg from falling on a rusty can. She had lost a significant amount of blood by the time she arrived at the hospital with her parents. Neither the child nor her parents agree to an emergency blood transfusion ordered by the physician.

Now consider the point of view of health professionals, and suggest strategies to respect both the physician's and family's points of view.
Physicians educated in North America tend to practice from a biomedical (scientific) rather than a holistic perspective. Ordering a treatment for a child reflects the ethical principles of beneficence, an obligation to make decisions to benefit the patient, and nonmaleficence, the intent to prevent harm. Given the emergency nature of many situations involving moral conflicts around blood products, many practitioners use plasma expanders whenever possible to prevent the need to transfuse blood. However, judicial decisions to use blood products for children sometimes are sought, and the blood is transfused against the judgment of the parents.
A 10-year-old client sustained a deep laceration on her leg from falling on a rusty can. She had lost a significant amount of blood by the time she arrived at the hospital with her parents. Neither the child nor her parents agree to an emergency blood transfusion ordered by the physician.

Think about your response as the nurse providing care to the child and family. How would you participate in the decision-making process?
The answer should include such steps in ethical problem solving as collecting as much information as possible; identifying if surrogate decision makers exist; seeking consultation on all possible courses of action; identifying strengths and benefits of all courses of action; ensuring that the family is an active participant in any decision made; and collaborating with the physician and associated health professionals working with the family.
What factors or evidence led to changes in public health practice that reduced the infant mortality rates in the early 1900s?
By 1915, the infant mortality rate had decreased from 200 per 1,000 (the rate from 1850 to 1880) to 100 per 1,000 live births. Causes of death included communicable disease, poor nutrition, and epidemics of "summer diarrhea." Improvements in infant health stemmed from a national legislative focus on prenatal care and infant health services. Funding allowed the development of initiatives to promote the health of neonates. Regulations were enacted to improve the sanitation of milk, and artificial infant formulas were developed. All of these developments had an impact on mortality rates.
What evidence led to the initiation of school health nursing?
Many children in the early 20th century were absent or sent home from school because of illness. In the Northeast corridor of the United States, physicians inspected schools and examined students to identify infectious disease.
What were the roles of nurses in these historical beginnings of child healthcare services?
In the 1890s, Lillian Wald, RN, recognized the need for health promotion and disease prevention among New York's immigrant population, and in her center, The Henry Street Settlement, nurses actively sought improvements in social conditions affecting health.

In 1902, Wald assigned a nurse to a school as a pilot project that was successful in reducing absenteeism. This school nursing model soon spread to other cities in the United States and Canada. The nurses monitored for illness, educated about personal hygiene and disease prevention, and were successful in their goal to improve the health of children.
Chapter 5: Concepts of Growth and Development
...
■ Development unfolds in a predictable pattern, but at different rates dependent on the particular characteristics and experiences of each child.
...
■ Major theories of development encompass the psychosexual (Freud), psychosocial (Erikson), cognitive (Piaget), moral (Kohlberg), social learning (Bandura), and behavioral (Skinner and Watson) components of individuals.
...
■ The ecologic theory of Bronfenbrenner and the temperament theory of Chess and Thomas emphasize the interactions of the individual within the environment.
...
■ Resiliency theory examines risk and protective factors that hinder or help children and families when dealing with developmental and life crises.
...
■ Influences on the developmental process include one's genetic potential and a series of environmental influences unique to each family and individual.
...
■ The newborn period begins at birth and ends at about 1 month, and is characterized by adaptation to extrauterine life, establishing periods of varying alertness, and specific physical findings.
...
■ Infancy spans the time from 1 month to 1 year, and is marked by rapid physical growth, mastery of basic fine and gross motor skills, and beginning cognitive and language skills.
...
■ Toddlers range in age from 1 to 3 years, and become increasingly mobile and communicative. They master control over excretion and are known for exerting their own opinions and wishes to parents. Injury prevention and toilet training are specific parental teaching needs.
...
■ Preschool years range from 3 to 6 and are marked by increasing social skills. Most preschool children attend childcare programs and learn to play with other children. Continued mastery of physical coordination and language occurs.
...
■ School age spans the years from 6 to 1 2, when children mature in many areas. They show slow, steady growth until reaching puberty between 9 and 12 years, when a growth spurt marks increased height and weight, as well as sexual maturation.
...
School-age children play cooperatively with other children and participate in various school and community activities.
...
■ Adolescence occurs from about 1 2 years of age through the teen years. Adolescents establish their own identities distinct from parents and other adults. They are mature physically and cognitively. The peer group exerts the major influence at this age.
...
■ The nurse is involved in assessing development at each stage, and in providing anticipatory guidance to families to foster optimal development.
...
INTRODUCTION
Consider Sergio, who was introduced in the chapter-opening scenario. He is now 6 months of age and growing well. His mother has altered her work schedule to stay with him each day; she works for a few hours in the evening when her husband is home. One pair of grandparents live about 30 miles
away and visit frequently. The family has medical insurance but has had to budget carefully to pay household bills since Yolanda is working less and they have expenses connected with Sergio's care.
...
DESCRIPTION
Since they have no other children and have limited experience with children, Pepe and Yolanda, Sergio's parents, have all the needs of new parents. Due to prematurity, Sergio has additional needs for developmental surveillance and parental education. Sergio is 24.5 inches (62 cm) long and weighs 1 5 lb (6.8 kg). Some developmental milestones that the nurse observes include:

■ Personal social—smiles, watches his own hand
■ Fine motor—hands meet at midline, regards and watches small objects, and has begun to grasp a rattle
■ Language—turns to sounds and voices, squeals and makes a variety of other sounds
■ Gross motor—holds head steady when in sitting position; holds head and chest up using arms when prone
...
DISCUSSION
1 . Sergio and his parents have many challenges and yet possess many strengths. Using the theory of resilience, list the infant's and family's risks and protective factors.
Protective factors:
Baby is well loved and cared for.
Mother's work is flexible so she can care for him during the day.
Father is able to care for infant when mother is at work.
Grandparents are close and visit often.
Family has medical insurance and they access health care.
Care at the clinic is continuous with caring provider
Family is able to maintain housing, food, etc.
Risk factors
Prematurity predisposes infant to respiratory infections and possible developmental delays
Parents are new parents with limited experience.
Income is limited and expenses for family have increased.
2. Calculate Sergio's height and weight percentiles. Consult the growth grids in Appendix Aand the Skills Manual for correct analysis. Since he is steadily growing, what summary can you provide for Sergio's parents? What nutritional advice should you provide for them?
Sergio is just below the 3rd percentile for length and at the 10th percentile for weight. It can be expected that Sergio will be small for his age, but since his growth remains steady, he is fine. The nurse should encourage Sergio's mother to continue to breast feed him, although he should be on supplemental iron. If they haven't already, the parents should begin solid foods, offering one food at a time. Traditionally babies start on rice cereals and progress to vegetables and fruits.
3. Analyze Sergio's developmental milestones. Consult the list of expected milestones in this chapter and on the Denver II Developmental Test in Chapter 9. What skills will Sergio learn next? What specific suggestions do you have for his parents as they seek to encourage his development?
Personal-Social: Sergio will work for a toy and begin to be interested in feeding himself
Fine Motor: Sergio will begin reaching for objects and will develop object permanence
Language: Sergio will continue to develop speech sounds, babble, and say "mama and dada"
nonspecifically. He will enjoy imitating parents' speech sounds
4. Assume that you are the nurse in the clinic where Sergio receives health care. Briefly outline the physical measurements, developmental observations, and family assessments that you will complete at each visit.
Physical measurements: length, weight, occipital frontal circumference, all charted on a percentile chart and monitored according to child's individual trend
Development: Summary of personal social, fine motor, language, and gross motor development relative to established norms and calibrated according to prematurity
Family Assessments: Evaluation of risk and protective factors, family strengths and areas for growth; family resources and coping strategies; parental knowledge regarding child care.
animism
The process of attributing lifelike qualities to nonliving things; common in thoughts of young children.
assimilation
Adopting and incorporating characteristics of a new culture within one's practices.
associative play
A type of play that emerges in preschool years when children interact with one another, engaging in similar activities and participating in groups.
Attachment
A strong emotional bond between people.
centration
Focus on only one particular aspect of a situation; common in thoughts of preschoolers.
cephalocaudal development
The process by which development proceeds from the head downward through the body and toward the feet.
collective monologue
Speaking in separate conversations even though each person waits for the other to speak; common in speech of preschoolers.
conservation
The knowledge that matter is not changed when its form is altered.
cooperative play
A type of play that emerges in school years when children join into groups to achieve a goal or play a game.
defense mechanisms
Technique used by the ego to unconsciously change reality, thereby protecting the individual from excessive anxiety.
Development
An increase in capability or function.
dramatic play
A type of play in which a child acts out the drama of daily life.
Ecologic theory
A theory of development that emphasizes the importance of interactions between the developing child and the settings in which the child lives.
ego
The realistic part of the person, which develops during infancy and searches for acceptable methods of meeting impulses.
egocentrism
The inability to consider the perspective of another; seeing things only from one's own point of view.
expressive jargon
Use of unintelligible words with normal speech intonations as if truly communicating in words; common in toddlerhood.
expressive speech
Words a young child can speak; usually less than the child is able to understand (receptive speech).
Growth
An increase in physical size.
id
The basic sexual energy that is present at birth and drives the individual to seek pleasure.
magical thinking
The belief of young children that events occur because of their thoughts or wishes.
mutagenesis
Permanent changes in the fetus' genetic material.
Nature
The genetic or hereditary capability of an individual.
Nurture
The effects of environment on an individual's performance.
Object permanence
The knowledge that an object or person continues to exist when not seen, heard, or felt.
parallel play
A type of play that emerges in toddlerhood when children play side by side but demonstrate little or no social interaction.
protective factors
Characteristics of a child and family that provide strength and assistance in dealing with a crisis.
proximodistal development
The process by which development proceeds from the center of the body outward to the extremities.
puberty
Period of life when the ability to reproduce sexually begins, characterized by maturation of the genital organs, development of the secondary sex characteristics, and the onset of menstruation in females.
receptive speech
The ability to understand words.
Resilience
The ability to function with healthy responses, even during significant stress and adversity.
risk factors
Characteristics of a child or family that promote or contribute to health system challenges.
Self-efficacy
A person's belief that he or she can change behavior to produce a desired outcome.
solitary play
Playing alone, with one's self.
superego
A moral and ethical system that develops in childhood and contains a set of values and conscience.
teratogenesis
Abnormal development of the fetus.
transductive reasoning
Connecting two events in a cause-effect relationship simply because they occur together in time; common in thoughts of preschoolers.
1 . The nurse notes that a 6-month-old infant boy who weighed 7 pounds at birth now weighs 15 pounds. Based on the evaluation of the infant's current weight, what is the nurse's next action?

1 . Ask the parent why the child does not eat enough.
2. Immediately inform the physician.
3. Chart the assessment.
4. Teach how not to overfeed the baby.
3. Chart the assessment.

Rationale: The baby's weight should be just about double the birth weight by 6 months. The other options treat the weight as if it is either too high or too low. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Evaluation; Learning Outcome: Synthesize information from several theoretical approaches to plan assessments of the child's growth and developmental milestones.
2. When planning nursing care for a hospitalized 9-year-old child, which intervention is most developmentally appropriate?

1 . Encourage the child to continue schoolwork.
2. Provide a separate recreation room for activities.
3. Encourage the child to brush teeth twice a day.
4. Offer medical equipment for play.
1.; Encourage the child to continue schoolwork.

Rationale: The developmental task ofa 9-year-old is industry according to Erikson; thus, the nurse should encourage the continuation of schoolwork. The separate recreation room is appropriate for adolescents, toddlers need reminders to brush, and playing with medical toys is appropriate for preschool-age children. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning; Learning Outcome: Plan nursing interventions for children that are appropriate for the child's developmental state and that apply developmental theories and frameworks.
3. A mother is watching her school-age child learn self-care techniques after being recently diagnosed with type 1 diabetes. Which is a correct statement?

1 . "Bandura's theory states children learn new behaviors best when imitating others."
2. "Erikson's stages describe school-age children learning by attaining goals."
3. "Piaget believes learning will take place more quickly when abstract thinking develops."
4. "Freud's description of personality development affects learning ability."
1. "Bandura's theory states children learn new behaviors best when imitating others."

Rationale: Goal attainment, developing abstract thinking, and personality development are not as closely related to learning self-care as is Bandura's social learning theory, which is described in option 1. Cognitive Level: Application; Client Need: Health Promotion and Maintenance; Nursing Process: Evaluation; Learning Outcome: Plan nursing interventions for children that are appropriate for the child's developmental state and that apply developmental theories and frameworks.
4. During a developmental assessment, a parent complains that she has a "difficult" toddler. What advice would the nurse offer to the parent?

1 . "Toddlers are flexible. Accepting new rules will occur quickly."
2. "Do not expect the child to adapt quickly to new situations."
3. "Encourage associative play and this will get better."
4. "Spanking your child will make the difficult behavior improve."
2. "Do not expect the child to adapt quickly to new situations."

Rationale: Toddlers are not flexible and do not adapt to anything quickly. Associative play does not occur until preschool age, and spanking should not be encouraged. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning; Learning Outcome: Use data collected during developmental assessments to plan appropriate nursing interventions that promote development ofchildren and adolescents.
1. A 4-year-old who has been toilet-trained becomes incontinent when hospitalized for surgery. The most appropriate nursing diagnosis based on this assessment finding is:

1. Growth and Development Altered related to incontinence.
2. Ineffective Individual Coping related to hospitalization.
3. Urinary Elimination, Altered related to incontinence.
4. Coping, Defensive related to stress of hospitalization.
4. Coping, Defensive related to stress of hospitalization.

Rationale: A toilet-trained 4-year-old who becomes incontinent during hospitalization is coping with the stress of this experience through the defense mechanism of regression. This is an effective means of coping for a child this age.
2. A 14-year-old has been diagnosed with insulin-dependent diabetes. Which technique is most appropriate in order to facilitate coping with this diagnosis?

1. Give the adolescent specific instructions.
2. Introduce the adolescent to another teenager who is successfully managing his diabetes.
3. Warn the teen of the consequences of noncompliance.
4. Encourage increased dependence on parents for several weeks.
2. Introduce the adolescent to another teenager who is successfully managing his diabetes.


Rationale: The adolescent benefits from meeting teens who are successfully managing a similar diagnosis. The adolescent might not respond well to being instructed what to do. Although the teen needs information related to consequences of noncompliance, this should never be in the form of a warning. In addition, this information would not facilitate coping with the diagnosis. The teen needs to remain as independent as possible. Although parents must learn the information as well, the teen still is encouraged to be very involved in his care and to be as independent as possible.
3. Which toy is most age appropriate for a 2-year-old?

1. Playhouse
2. Nesting cups
3. Mobile
4. Toy vacuum cleaner
4. Toy vacuum cleaner

Rationale: A 2-year-old benefits from having push-pull toys that encourage movement and autonomy. Nesting cups are appropriate for older infants. Mobiles are appropriate for young infants. Playhouses are appropriate for preschool-age children.
4. Which intervention is most appropriate in order to facilitate the development of trust in an infant who is hospitalized?

1. Place pictures of the child's family at the bedside.
2. Encourage the parents to room in and participate in care.
3. Offer the infant a pacifier.
4. Play tapes of the mother's voice.
2. Encourage the parents to room in and participate in care.

Rationale: Encouraging parents to stay at the bedside and participate in care promotes a sense of trust in the infant. Placing pictures at the bedside and playing tapes of the mother's voice are more appropriate to decrease the feeling of separation in an older infant and toddler; however, they do not promote the development of trust. A pacifier satisfies the oral needs that an infant has, not the development of trust.
5. Which observation is most representative of the type of play usually seen in toddlers?

1. Two children putting a puzzle together
2. A child who sits on the floor by himself playing with blocks
3. The child who dresses up like a fireman
4. Two children sitting side by side, each playing with a toy truck
4. Two children sitting side by side, each playing with a toy truck

Rationale: Two children sitting side by side playing with similar toys is an example of parallel play, which dominates in toddlers. The child who sits on the floor by himself playing with blocks is demonstrating solitary play, seen in infants. The child who dresses up like a fireman is demonstrating dramatic play, seen in preschool-age children. Two children putting a puzzle together are demonstrating associative play, also characteristic of preschool-age children.
6. The nurse notes that a 5-month-old has significant head lag when she attempts to pull the infant to a sitting position. Based on this assessment, the nurse recognizes that the infant:

1. Has some degree of mental retardation.
2. Is developing normally.
3. Needs further assessment and evaluation.
4. Has been neglected by the parents.
3. Needs further assessment and evaluation.

Rationale: Head lag should not be present in a 5-month-old. The nurse cannot conclude that the child has been neglected or has some degree of mental retardation based on head lag alone. The child needs further assessment and evaluation.
7. The nurse is preparing a 4-year-old for surgery. Which technique is most appropriate?

1. Allow the child to handle safe medical equipment.
2. Limit the teaching to one 1-hour session.
3. Use an anatomically correct doll to explain the procedure.
4. Explain to the child that she will be put to sleep for the procedure.
1. Allow the child to handle safe medical equipment.

Rationale: The preschool-age child learns well by participating in therapeutic play, such as handling safe medical equipment. Terms such as "put to sleep" might be misinterpreted by the child. Anatomically correct dolls are not appropriate for preschool-age children. The preschool-age child benefits from several short teaching sessions.
8. Which nursing intervention is most developmentally appropriate for a hospitalized 10-year-old?

1. Allow the child to assist with dressing changes.
2. Encourage the child to play with safe medical equipment.
3. Encourage dependency on parents while the child is hospitalized.
4. Obtain a complete health history from the child.
1. Allow the child to assist with dressing changes.

Rationale: Allowing the child to participate in care and assist with procedures such as dressing changes promotes the development of industry, characteristic of school-age children. Playing with safe medical equipment is more appropriate with preschool- and young school-age children. Encouraging dependency does not promote the development of industry and could lead to a sense of inferiority. The 10-year-old probably will not be able to give a complete health history.
9. The nurse notes that a 6-month-old infant who weighed 7 pounds at birth now weighs 15 pounds. What is the nurse's evaluation of the infant's current weight?

1. The infant should be hospitalized for failure to thrive.
2. The infant's weight is appropriate for his age.
3. The infant needs weekly follow-up to assess weight.
4. The infant has been consuming more calories than needed.
2. The infant's weight is appropriate for his age.

Rationale: The infant should double his birth weight by 5 to 6 months; therefore, the weight of 15 pounds is appropriate. There is no need for weekly weights in an infant who is thriving. There is no indication of failure to thrive, nor is there any indication that the child has been consuming too many calories.
10. A child who weighed 8 pounds at birth should weigh __________ pounds at 12 months of age.
24

A child should double his birth weight by 5-6 months and triple it by one year.
What are some of the values that adolescents might develop?
These values might relate to respect for others, responsibility for actions, or establishing goals.
What questions can you ask teens that might help you to learn some of their values?
Examples of some questions are: "Have you started to think about what you will do after graduation?" "What sports do you enjoy?" "Do you ever drive after drinking?" "What happens when you do something your parents do not approve of?"
Why would it be important for a nurse to examine adolescent identity information in caring for teens in the hospital or community?
The nurse needs to realize that adolescence is a time when the teen has a need to leave the past and be different—to establish self-identity. Rules might be broken in the quest to establish self-awareness. If the teen is diagnosed with a chronic illness during this time, difficulties may arise. The teen might rebel because the illness is interfering with the need for independence and control. Introducing the adolescent to a teen who has managed the same problem is generally very successful.
When preparing a preschooler for a procedure, do you think it would help to have someone who has had the procedure before come and talk with the child? Will the child be interested in hearing the perspective of another?
Probably not. A more effective approach is to teach the child what it will feel like to her. Show her pictures, take her on tours, and let her touch and use stethoscopes and other materials to increase her understanding.
How would you prepare a preschooler for hospitalization?
Simple explanations, along with the use of play, are effective ways to prepare preschool-age children for hospitalization. Puppets, pictures, tours, stories, dolls, and dress-up clothes all are appropriate items to use in preparation of a child this age.
The preschool-age child's grasp of meaning is generally literal. Give examples of words or phrases that might have important implications in the healthcare setting.
Phrases such as "put to sleep," "dye," and "a little stick in the arm" will mean different things to the preschool-age child than they do the adult. The nurse needs to explain procedures in simple terms without using phrases that will be misinterpreted. "You are going to go to sleep for a little while" is more appropriate than "put to sleep." The child might perceive "put to sleep" as what happened to her pet. "You will be given some medicine that will help us see pictures of the inside of your body" is more appropriate than using the word dye. The word dye might be interpreted as death, or the child may think she is going to change colors when the medication is given. "Medicine under the skin" is more appropriate than "stick in the arm" for the child who is receiving an injection. "Stick in the arm" might create a vision of an actual tree limb in the arm for the preschool-age child.
This chapter has summarized several theories that are important to consider when studying child developmental progression. What is a theory, and why do we study theories?
A theory is an explanation or construct that is formulated in a response to observations as a proposition to clarify those observations. Often, a person makes observations and seeks to understand them; formulating a theory makes this easier. For example, Freud observed certain commonalities in his psychiatric clients and formulated a theory of child development that explained the relationships between child experiences and adult psychiatric illness.
Once a theory is formulated, it is tested through research to see if it holds true in various circumstances. It might be refined, changed, or even found to offer little assistance in understanding an issue. Consider the developmental theories presented in this chapter and ask yourself these questions:
- What observations led the scientist to formulate the theory?
- What are the crucial concepts or constructs of the theory?
- Has the theory been tested?
- Did the testing support the theory or demonstrate problems with it?
- How can each theory be applied in nursing to help you better understand children and their families?
Freud developed the theory of psychosexual development. His use of psychoanalytic techniques was the impetus for the development of this theory, proposing that early-childhood experiences form the unconscious motivation for actions in later life. Freud developed a theory that sexual energy is centered to specific parts of the body and described the id, ego, and superego. Freud also described the use of defense mechanisms. His theory of childhood has been criticized because it was based on his works with adults. Freud's theory can be applied to nursing care of children and families, especially when viewing the oral needs of the infant, the anal focus of the toddler who is toilet training, and the preschool-age child's concern about sexuality and thus need for privacy. Erik Erikson's theory of psychosocial development established eight psychosocial stages that cover the lifespan. Erikson studied under Freud's daughter but focused on the psychosocial, rather than the psychosexual, nature of individuals. Erikson's theory focuses on the consequences to the individual when needs are either met or unmet. Erikson's theory is directly related to the nursing care of children, with behaviors specific to each age group being explained within each developmental stage. Jean Piaget developed a theory of cognitive development based on his observations of his own three children. He also studied the intellectual abilities of children and focused on child psychology and its application to education. Piaget's theory is essential to pediatric nursing, because the nurse must understand the child's level of cognitive thinking to formulate teaching plans and design activities for the child. Lawrence Kohlberg used Piaget's theory as a basis to develop his theory of moral development. He worked with children in several countries in developing his theory. His work has been criticized for lack of cultural sensitivity. Moral reasoning is applicable to the healthcare setting. Children can be involved in decision-making processes as appropriate. The nurse should assist the child and family in appropriate decision making.
Remember the ecological theory of Bronfenbrenner and the systems or levels of interactions for each child. Assess a child you have seen in a clinical experience recently for the important microsystem, mesosystem, exosystem, and macrosystem influences. Refer to Table 5-4 in the text for a review of some areas you might consider. Then as you plan care for that child and family, ask yourself these questions:
- How does the child influence each system?
- How is the child influenced by each system?
- Where does this lead you in planning interventions for the child?
In your assessment, you should have considered the influence of parents, significant others, childcare arrangements, school, neighborhood contacts, clubs, friends, peers, and the religious community. By taking into account the influence of each of these for each child, the nurse determines how many support systems the child has, and how involved the child is in other activities. Hospitalization will impact the child's ability to participate in these activities. The nurse should assist the child to have continued contact with the influences that are most important. This will be very individualized depending on the circumstances for the child you focused on.
A 10-year-old is diagnosed with type 1 diabetes and will require daily dietary management and injections of insulin.

List the individual characteristics and past experiences that could act as risk factors for this child's adaptation to the disease of diabetes.
Risk factors for this child might include limited close relationships with adults, as with the child who lives in a single-parent home and has limited contact with extended adult family. Another risk factor is a slow-to-warm temperament. A child with a slow-to-warm temperament might not be receptive to the diabetes nurse educator in the beginning, initially appearing disinterested in learning. A child who has had a bad experience with finger sticks, venipuncture, and injections might be resistant to procedures necessary for a child newly diagnosed with diabetes.
A 10-year-old is diagnosed with type 1 diabetes and will require daily dietary management and injections of insulin.

List the individual characteristics and past experiences that could act as protective factors in the child's adaptation to the disease of diabetes.
The child who has had positive experiences with new people might be very receptive to those who are interacting with him in the healthcare setting. A child with an easy temperament is likely to be more receptive to learning about his illness.
Chapter 16: Nursing Care of the Hospitalized Child
...
■ Hospitalization is a stressful event for all children and their families, especially when the hospitalization is unplanned and sudden.
...
■ The understanding of children about their illnesses and hospitalizations is based on cognitive and psychosocial stage/level, and upon previous healthcare experiences.
...
■ Nurses assess the impact of the child's illness or hospitalization on the family unit and provide individualized family-centered care.
...
■ Families are always disrupted by a child's hospitalization, and various approaches can help them to understand the process and cope more successfully with this challenge.
...
■ When hospitalization is planned, both the child and parents can prepare for the experience. Nurses assist this process by teaching about what to expect.
...
■ A teaching plan includes goals and expected outcomes, interventions needed to achieve the specified goals, and a method and time for evaluation of the expected outcomes. How the teaching plan is implemented depends on the unique characteristics of the child/family to be taught.
...
■ The child is prepared for procedures using a variety of techniques taking into consideration the child's developmental age, coping abilities, and previous experience.
...
■ Strategies such as child life programs, rooming in, therapeutic play, and therapeutic recreation help meet the psychosocial needs of the hospitalized child.
...
■ The nurse assists the family to plan for the child's long-term healthcare needs and home care issues. Culturally competent care is integrated throughout all provisions of care.
...
Animal-assisted therapy
Use of a specially trained animal to provide comfort, companionship, and distraction during an illness; often used in hospitals.
INTRODUCTION
Recall Tiona, the child described in the chapter beginning. She
is a 5-year-old who was admitted to the hospital for a tonsillec-
tomy and adenoidectomy.
...
DESCRIPTION
Because of her history of sleep apnea, Tiona was scheduled to
spend the night in the hospital to monitor her for any poten-
tial respiratory complications. Following the operation, Tiona
refused to drink liquids because she was afraid it would hurt
when she swallowed. After receiving intravenous pain medica-
tion, Tiona realized that she could swallow without too much
pain and began to eat Popsicles and drink liquids. She was
then switched to oral pain medication. The next morning
Tiona is drinking liquids well enough that she is to be dis-
charged home.
...
DISCUSSION
1 . What information should the nurse include in the discharge teaching plan for Tiona's mother?
a. Medication instructions and discussion re. pain management
b. Signs and symptoms to monitor for including: bleeding, inability to swallow fluids/soft food, inadequate po fluid intake, increased pain unrelieved by medication as ordered
c. Encouragement of mother to promote play activities, such as medical play or art work, so that Tiona can work out her feelings re. the hospitalization
d. Follow up appointment
e. Phone numbers to call if they have questions
2. As Tiona and her mother are preparing to leave the hospital, Tiona says, "I am going to be good so I do not have to come to the hospital anymore!" How should the nurse respond?
Assess what she means first: "Why do you think you had to come to the hospital? Did you think you were here because you weren't good at home?" After finding out what she meant...then you can respond accordingly to dispel the reason or address that her tonsils were making her sick so they needed to be taken out so she can feel better. "It had nothing to do with anything you did."
3. Tiona's mother states that she is worried that her daughter will not drink enough at home. What can the nurse suggest to Tiona's mother to encourage her to drink fluids?
Encourage fluids that she likes, e.g. popsicles, smoothies, milkshakes, etc. Let her keep track of how much she drinks and decorate the chart with stickers as a reward.
4. What are symptoms of dehydration that Tiona's mother should watch for over the next few days?
Sunken eyes, dry skin and mucous membranes, dizziness upon sitting up or going from sitting to standing; change in level of consciousness (more lethargic and tired); minimal urine output.
5. Children Tiona's age have many fears and stressors related to hospitalization and surgery. How can her mother assist Tiona to express her feelings about the hospital experience once she is home?
Encourage medical play with dolls/equipment; encourage activities such as arts and crafts where she can express her feelings; read books to her that discuss hospitalization and ask her about her feelings.
Child life specialist
Trained professional who plans therapeutic activities for hospitalized children.
Dramatic play
A type of play in which a child acts out the drama of daily life.
Rehabilitation
Assisting a child with physical or mental challenges to reach his or her fullest potential through therapy and education that considers the physiologic, psychologic, and environmental strengths and limitations of the child.
Rooming in
Practice in which parents stay in the child's hospital room and care for the child.
Separation anxiety
Inconsolable crying and other signs of distress in an infant when parents are not present, commonly beginning in the second half of the first year of life.
Stranger anxiety
Wariness of strange people and places, often shown by infants between six and 18 months of age.
Therapeutic play
Planned play techniques that provide an opportunity for children to deal with fears and concerns related to illness or hospitalization.
Therapeutic recreation
Using recreational therapy interventions to improve functioning of individuals with illness or disabling conditions.
Treatment room
A special room utilized for the pediatric population for procedures such as intravenous starts, lumbar punctures, and blood drawing. The treatment room is utilized rather than the child's own hospital room so that the child always has a "safe" environment and comfort zone by knowing that no unpleasant or painful procedures will occur in his or her room.
1 . The siblings of an injured child are coming to visit their sister who is recovering in the hospital. They ask the nurse, "Is my sister going to die?" What is the nurse's most effective response?

1 . "No, and soon she will be able to go home with you."
2. "Why do you think that your sister is going to die?"
3. "Do you know what it means to die?"
4. "I think you should be asking your parents that question."
1. "No, and soon she will be able to go home with you."

Rationale: It is important for the nurse to be honest and base the answer on age and developmental level of the siblings."Why" questions are confrontational and nontherapeutic and should never be asked offamily members. It is more appropriate to prepare them for what they might see in their sister's room and allow them to ask questions. Answering their question with a question will make them think the nurse is hiding something. It would be better to answer their question honestly on a level developmentally appropriate. Putting this question off will worsen fears about seeing their sister. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Implementation; Learning Outcome: Apply family-centered care principles to the hospital setting.
2. How can the nurse best limit the amount of separation anxiety that the hospitalized toddler will experience?

1 . Reduce the amount of time spent with the child when the parents are not present.
2. Discourage the amount of time the parents hold their child while hospitalized.
3. Encourage the parents to leave the child's room when care is being provided.
4. Encourage parental involvement in the child's care and suggest rooming-in if possible.
4. Encourage parental involvement in the child's care and suggest rooming-in if possible.

Rationale: Parents should be encouraged to room-in with and hold their child and to participate in the child's care as much as possible. The child's anxiety will increase when the parent leaves or the child is left alone. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Assessment; Learning Outcome: Apply family-centered care principles to the hospital setting.
3. Which behavior by a child's parents is the best indicator that they understand how to administer medication to the child at home following surgery?

1 . The parents sign the written discharge instruction verifying understanding of the instructions.
2. The parents give the medication to the child using the appropriate technique in the nurse's presence.
3. The parents state they understand how to administer the medication and deny questions.
4. The parents state they can give the medication to the child using appropriate technique.
2. The parents give the medication to the child using the appropriate technique in the nurse's presence.

Rationale: While all four options indicate understanding, watching the parents correctly administer the medication provides the most information about their understanding. Cognitive Level: Analysis; Client Need: Physiological Integrity; Nursing Process: Evaluation; Learning Outcome: Evaluate the effectiveness of teaching strategies used with the hospitalized child and the family.
4. Which is the most critical factor used in evaluation of readiness to learn?

1 . Family expectations
2. Developmental level
3. Education level
4. Timing
4. Timing

Rationale: Parents and children who are stressed or preoccupied will not be successful in learning. Choosing the correct time is critical to the child's and parent's learning. Developmental level and education level have little to do with readiness to learn and more to do with choosing appropriate teaching strategies. Family expectations are an important factor in readiness to learn. However, timing is the better answer as appropriate timing sets the stage for effective teaching chosen with family expectations in mind. Cognitive Level: Analysis; Client Need: Safe, Effective Care Environment; Nursing Process: Evaluation; Learning Outcome: Evaluate the effectiveness ofteaching strategies used with the hospitalized child and the family.
1. Separation anxiety is one of the major stressors of hospitalization for a toddler. How can the nurse best limit the amount of separation anxiety that the hospitalized toddler will experience?

1. Reduce the amount of time spent with the child when the parents are not present.
2. Encourage the parents to leave the child's room when care is being provided.
3. Encourage the parents to limit the time they hold their child.
4. Encourage parental involvement in the child's care and suggest rooming in if possible.
4. Encourage parental involvement in the child's care and suggest rooming in if possible.

Rationale: Parents should be encouraged to room in with their child and to participate in their child's care as much as possible. Asking the parents to leave the room will cause anxiety in the child. Parents should be encouraged to remain with and participate in the care of their hospitalized child. Parents should be encouraged to hold their child as much as the child's condition allows. The nurse should spend as much time as possible with the child when the parents are not present to decrease the amount of anxiety the child experiences.
2. A 16-year-old female has been admitted to the hospital because of a serious respiratory infection with a diagnosis of possible tuberculosis. She has been placed on respiratory isolation in a private room. Knowing that peers are important, what should the nurse suggest?

1. Drawing pictures of her feelings to give to her peers
2. Placing the child in a room with a roommate of the same age
3. Having friends visit her often
4. Maintaining contact with her friends by telephone
4. Maintaining contact with her friends by telephone

Rationale: Telephone contact with friends should be encouraged for the hospitalized adolescent. Disposable equipment is contaminated and should be discarded. In this situation, peer visitation would not be encouraged, because the client is in respiratory isolation for possible tuberculosis. She would not want to expose her friends to the disease. Drawing pictures symbolizing her feelings to give to her friends is not age appropriate.
3. A 4-year-old tells the nurse that she is bad and that's why she is in the hospital. What is the nurse's most appropriate response?

1. "Don't be silly."
2. "Let's call your mom and see what she has to say about it."
3. "What did you do that makes you feel like you are bad?"
4. "You are here so we can help you feel better, not because of anything you might have done."
4. "You are here so we can help you feel better, not because of anything you might have done."

Rationale: Preschoolers do not fully understand cause and effect and what causes illness. They also frequently view illness as punishment. The nurse needs to be clear about why the child is in the hospital without giving any physiological information that the child cannot understand. The nurse should not discount the statement by saying "Don't be silly." It also does not show the child that whatever behavior made her feel like she was bad has no relationship to her hospitalization. Children of this age may feel two unrelated events have a cause-and-effect relationship. Open-ended statements focus the child on behavior she thinks is bad instead of assuring her that her behavior is unrelated to the reason for hospitalization. Calling the mom to get her input about the child's behavior is not related to the hospitalization and does not focus on helping the child to understand why she is hospitalized.
4. A preschooler's response to hospitalization includes the fear of bodily injury or mutilation. How can the nurse best reduce this fear?

1. Give thorough explanations of procedures to the child.
2. Use Band-Aids or bandages after invasive procedures to reassure the child that his body will not leak and that body parts will not fall out.
3. Avoid any discussion of impending procedures with the child.
4. Ask parents to restrain the child for procedures because the child trusts them.
2. Use Band-Aids or bandages after invasive procedures to reassure the child that his body will not leak and that body parts will not fall out.

Rationale: Preschool-age children fear bodily injury and mutilation and are concerned that they will leak or that body parts will fall out when they have had an operation or when they have had a procedure involving a needle stick. Band-Aids and bandages help reassure them that their body will remain intact. Parents should be allowed to be present for the procedure, but they should be there for support, not restraint. Preparation for procedures is essential to decrease the preschooler's anxiety.
5. A 4-year-old has been hospitalized for several days, and his parents have decided to return to work during the day and then spend the evening and night with him. They have informed the nurse that they will return around 5:30 or 6:00 p.m. During lunch, the child asks the nurse when his parents will return. What is the most appropriate response by the nurse?

1. "Your parents will return between 5:30 and 6:00 p.m."
2. "Your parents will return around suppertime."
3. "Your parents will return when they get off work"
3. "I do not know when your parents are going to return."
2. "Your parents will return around suppertime."

Rationale: Preschoolers need to know when their parents will return as much as that is possible. Relating the response to an activity that the child will understand is appropriate. Being as specific as possible will help as well. The child cannot relate a time frame to "when they get off work." This child also will not understand 5:30 to 6:00 p.m. due to limited understanding of time concepts but will understand "suppertime." Giving the child no information will only increase anxiety. In a situation where the nurse does not know, phoning the parents might be beneficial.
6. The parent of a hospitalized infant expresses the desire to hold her infant who has been hospitalized with a bacterial infection. What is the most appropriate action by the nurse?

1. Inform the mother that holding the infant may cause the intravenous line to become dislodged.
2. Show the mother how to hold the infant so that intravenous lines are not jeopardized.
3. Ask the mother why she wants to hold the infant.
4. Tell the mother that the infant should rest.
2. Show the mother how to hold the infant so that intravenous lines are not jeopardized.

Rationale: Parent-infant attachment is critical to the infant's development; therefore, the nurse should assist the mother to hold the infant in a way that does not jeopardize intravenous lines or equipment. Giving the mother messages that imply that she should not hold her child increases parental anxiety and jeopardizes appropriate development for the infant. The nurse already should understand why the mother wants to hold the infant.
7. A hospitalized 9-year-old states that he does not understand why he needs to have an operation. Based on this statement, the most appropriate nursing diagnosis for this child is:

1. Social Isolation related to hospitalization.
2. Fear of Mutilation related to surgical procedure.
3. Anxiety related to surgery.
4. Knowledge Deficit: Need for Surgery related to lack of previous teaching.
4. Knowledge Deficit: Need for Surgery related to lack of previous teaching.

Rationale: Although all of the diagnoses might be appropriate, the one that corresponds directly to the child's statement is Knowledge Deficit related to need for surgery.
8. Which behavior by a client's parent is the best indicator that he understands how to administer medication to his child at home following surgery?

1. The parent gives the medication to the child using appropriate technique.
2. The parents state that he understands how to administer the medication.
3. The parent signs the written discharge instruction, verifying understanding of the instructions.
4. The parent describes to the nurse how he will give the medication.
1. The parent gives the medication to the child using appropriate technique.

Rationale: Although all of the answers indicate some degree of understanding, the best way to determine understanding is to actually have the parent demonstrate by administering the medication as the nurse observes technique.
9. The nurse is providing care for a hospitalized 10 year-old. Which assessment datum collected by the nurse validates that the child is in the appropriate stage of development?

1. The child does not participate in his care.
2. The child states that he wants to help remove the bandage from his abdomen.
3. The child cries whenever his parents leave.
4. The child kicks and screams when venipuncture is performed.
2. The child states that he wants to help remove the bandage from his abdomen.

Rationale: The school-age child is developing independence. The child who asks to help remove his dressing is demonstrating the development of industry. A child who will not participate is showing signs of regression. School-age children might want parents to stay, but they should not be demonstrating signs of separation anxiety at this age. A 10-year-old who kicks and screams with procedures is not demonstrating coping mechanisms characteristic of most school-age children.
10. For maintenance of normal body fluid requirements, a child undergoing surgery who weighs 9.6 kg will need __________ mL of fluid per hour in addition to any losses or deficits.
40 mL

Rationale: The equation for calculating maintenance fluid is: 100 mL of fluid for the first 10 kg of body weight 50 mL of fluid for the second 10 kg of body weight 20 mL of fluid for the remaining body weight So for the child who weighs 9.6 kg: 9.6 kg × 100 mL = 960 mL per day or 40 mL per hour.
Describe appropriate methods for preparing children for procedures. Identify techniques appropriate for each developmental level.
Infants will not receive an explanation because parents are given the information. Toddlers should be given a brief explanation just prior to the procedure. A story read to them, or pictures, might be helpful. Preschool-age children also need simple explanations with the opportunity to touch or play with equipment. Toddlers learn well through therapeutic play with safe medical equipment. Simple drawings and stories may be helpful. School-age children will need clear, thorough explanations and the chance to ask questions and have fears acknowledged. Drawings, pictures, books, and videos and handling equipment that will be used are also appropriate. Adolescents should receive clear explanations both orally and in writing. Videos and talking to someone of the same age range who has had a similar experience also are appropriate.
Describe appropriate methods for supporting a child during a procedure. Identify techniques appropriate for each age group.
For infants, touch, voice, a pacifier, and a bottle serve as distractions. A gentle but firm touch is reassuring to infants. Toddlers should be restrained securely. They should be allowed to cry and scream. Parents' presence will offer some comfort to the child. Allow choices that are acceptable for toddlers to make. This gives them some control over their situation. Preschool-age children also should be restrained as needed. They also should know that it is okay to cry if they want. They can be taught simple coping measures such as counting to 10. School-age children should be given explanations throughout the procedure. These children also can be taught stress-control techniques such as breathing exercises, imagery, and so on. Adolescents should be assisted to use stress-control techniques such as breathing exercises and imagery.
Describe appropriate methods for supporting a child after a procedure is completed. Identify techniques appropriate for each age group.
Parents or staff should hold, rock, and/or sing to the infant after procedures. Toddlers need comfort as well, but they also generally like stickers or a special treat afterward. Preschool-age children need praise and comfort after procedures. They enjoy being given stickers as well. It is important for children this age to have a Band-Aid or bandage so they "will not leak" or "lose their body parts." Children this age might want to draw a picture afterward or play with safe or toy medical equipment after the procedure. School-age children should receive praise for cooperation. Younger school-age children might want stickers as well. Adolescents should be told when to expect results of lab tests and other procedures. Children of all ages need to be praised for their performance, regardless of their behavior during the procedure.
Chapter 20: Nursing Care of the Child with a Chronic Condition
...
■ A chronic condition is a long-term, ongoing condition that is expected to last 3 months or more and may involve any of the following alone or in combination: functional limitations, disfigurement, dependence on technology, medications, special diet for management of the condition, and requiring more healthcare services than a healthy child.
...
■ Approximately 10 million children in the United States have a chronic condition.
...
■ Children with special healthcare needs represent 15.6% of children in the United States, but they use 33.6% of total healthcare expenditures for children.
...
■ Chronic conditions can occur as a result of a genetic condition, congenital anomaly, injury during fetal development or at birth, complication of care after birth, serious infection, or significant injury.
...
■ Children who are medically fragile are those dependent on a medical device for survival or prevention of further disability.
...
■ A developmental delay results when there is failure to achieve anticipated developmental milestones during specific developmental stages.
...
■ Parents may experience many of the same responses to the diagnosis of a child's chronic condition as if they had experienced the child's death, including shock, disbelief, anger, denial, and despair. Siblings of the child with a chronic illness may have feelings of jealousy, resentment, anger, depression, and guilt.
...
■ The time of diagnosis is one of the most stressful times for families of children with chronic conditions as the parents wait anxiously for the outcome of diagnostic procedures. Other times associated with significant stressors for the family include developmental milestones, school entry, adolescence, planning for the transition to adult health and vocational services, and planning for long-term guardianship.
...
■ Moving the chronically ill child or technology-dependent child to the home setting is a life-changing decision for the family, and it must be done with collaboration between the family and the healthcare team.
...
■ Caregiver burden, the ongoing pressure of caring for children with special healthcare needs, causes fatigue and makes it difficult for the parents to meet other family obligations.
...
■ The financial burden of caring for a child with special healthcare needs is significant even when the family has health insurance.
...
■ In an effort to cope and feel a sense of control over the family's life, the parents may use normalization, a process of focusing on those aspects of family life and routine that are similar to other families while integrating the needs of the child with a chronic condition.
...
■ Sending the child to school has several benefits for the child and family, including socialization for the child beyond the immediate family, respite for parents, and promotion of a sense of normalization in the family.
...
■ An individualized education plan (IEP) is developed for a child with cognitive, motor, social, or communication impairments who needs special education services in the school setting. An individualized health plan (IHP) is developed for the child with medical conditions that need to be managed within the school setting.
...
■ Children who are medically fragile or dependent on technology are entitled to a free and appropriate education and education services in the school setting. The school administration is obligated to plan for and ensure that the personnel resources and equipment needed to provide care are consistently available.
...
■ An individualized transition plan (ITP) is developed for adolescents with a chronic condition in collaboration with the family to assist in identifying appropriate support programs, living arrangements, and employment for adult life.
...
■ The child with a chronic condition is more likely to be hospitalized than the child without a chronic condition. Sudden hospitalization resulting from exacerbation of the child's disorder places increased demands and stressors on the child and family.
...
■ Children with chronic health conditions require regular health promotion, health screening, and health maintenance care, as well as specialized health services to assist the child and family in the management of the condition.
...
■ The role of the nurse in caring for the child with a chronic condition includes providing health supervision from infancy to transition into adulthood, collaborating with the multidisciplinary healthcare team, and partnering with the family to manage the child's care at home.
...
■ Nurses who specialize in caring for children with complex chronic conditions may experience compassion fatigue as they continue their efforts to meet the ongoing needs of these families.
...
CRITICAL THINKING IN ACTION
Haley Leftwich is an 8-year-old girl with cerebral palsy. She had an intraventricular hemorrhage during her neonatal intensive care unit (NICU) hospitalization for prematurity. Haley lives with her mother and two older siblings, ages 10 and 13. Her parents divorced when Haley was 3 years old. She has frequent contact with her father, who she visits on weekends. Her father is supportive emotionally, physically, and financially in the care of Haley and her siblings. Haley's mother is the full-time primary care provider. Routine care includes hygiene, supplemental enteral tube feedings to promote adequate nutrition in between oral feedings, range of motion (ROM) exercises, and home-schooling. Haley uses her motorized wheelchair without difficulty, and her mother has decided that she would benefit from social interaction and a structured educational environment at the local public school. Her family asks the clinic nurse and case manager at the cerebral palsy clinic for assistance in helping with planning Haley's entry into school. How can the clinic nurse and case manager assist Haley and her family in this transition? What special arrangements are needed to permit a child to receive care for a chronic condition while at school? What measures can be taken to ensure an effective transition between home and school?
...
INTRODUCTION
Recall Haley, the child with cerebral palsy who will be attending school for the first time. Her mother had initially preferred homeschooling for Haley, and now wants to support her social development with other children. Haley's sister is in the local elementary school and, if possible, her mother would like Haley to attend the same school. A case manager is asked to assist with facilitating Haley's entry into school.
...
DESCRIPTION
The case manager coordinates a multidisciplinary meeting of the clinic nurse, physical therapist, physician, and Haley's family to review her health status and to discuss the transition to school. They also discuss potential accommodations needed for Haley's mobility limitations. A full educational evaluation has not yet been performed, and the family is encouraged to talk with the school system to initiate that process. The multidisciplinary team assists the parents in developing a plan for Haley's transition to school. Once her mother has signed consent, the case worker will ensure that needed medical records are transferred to the school for development of the IEP and IHP.
...
DISCUSSION
1 . What role will the clinic nurse and case manager have in helping develop Haley's IEP and IHP?
The clinic nurse and case manager will release information, which includes history & physical. They will provide assessment information regarding child's current health status and level of function. They will provide consultation regarding their assessment and care, so that there will be continuity between the disciplines in all settings. The clinic nurse can continue to be a good liaison between the school and health care providers to provide ongoing planning and evaluation. For the IHP, they will have to provide prescriptions and detailed instructions on medications and procedures that will occur at school.
2. What role will the school nurse have with the child, care-givers, teacher, and classmates during the facilitation of school entry?
The school nurse will receive and evaluate the child's information and formulate a plan of care for the educational environment. The information needs to be translated to the child's teachers, including daily routine, special procedures, and emergency care. He/she needs to assure that there are appropriate personnel to provide safe and effective care, which may include delegation and training. The school nurse will accompany the parents and the child to meet/greet the
classmates.
3. Based on Haley's age and developmental stage, what feelings, fears, and concerns might she be expected to experience related to entry into school? What interventions would be beneficial to Haley?
Assuming she is normal for age, she would be at the school age stage with the task of industry vs. inferiority. She may identify herself as inferior due to her inability to participate and perform in classroom/recess activities. She may have increased anxiety since she has not been in school (only home-schooled). She may have separation anxiety from her mother. Interventions include: Assessment of her current level of functioning, cognitively and socially. Work with the multidisciplinary team to design appropriate accommodations for her. She may want to start school on a part-time basis, and increase hours as she is able to cope and tolerate. Work with the teacher to identify a classmate "special friend" to help her adjust to the classroom. Provide opportunities for her to be successful.
4. What actions will the mother need to take in preparing the school personnel for Haley's health needs?
Her mother will transfer the records, assure that the medical information is at the school. She will meet with all appropriate personnel ahead of time, and collaborate to formulate the IHP and emergency care plan. She will bring in doctor's orders and prescriptions, and sign any parent consents required by the state/school for care. She will provide all equipment, medications, feedings, and supplies.
5. Haley's 10-year-old sister attends the same school. What effects of Haley's entry into school might the sibling experience?
The sibling may feel protective and want to help out with Haley's care. She may feel embarrassed by her sister's health condition. She might also resent the extra attention Haley is
getting at school, resulting in behavior problems and poor school performance.
accommodations
Services or special assistance provided in the school setting to ensure that a student with a physical or mental impairment has access to an appropriate education.
Caregiver burden
The burden family or caregivers feel when caring for the child with a chronic condition.
case manager
Person who coordinates health care to prevent gaps or overlaps.
children with special healthcare needs (CSHCN)
Children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require services beyond that usually required by children.
chronic condition
A health or medical condition that lasts or is expected to last three months or more.
chronic sorrow
A coping mechanism of periodic grieving.
compassion fatigue
An emotion that comes from knowing about the traumatizing events experienced by families and the stress from helping or wanting to help that family.
developmental delay
Failure to achieve anticipated developmental milestones during specific developmental stages.
disability
A limitation that interferes with a child's ability to fully participate in society.
Early intervention
Special services for infants and toddlers up to age 3 years who have developmental delay or are at risk for developmental delay.
individualized education plan (IEP)
Formulation of a specific learning approach for a child with a physical or mental disability, following thorough assessment of the child's capabilities and areas of need.
individualized family service plan (IFSP)]
Developed for the early intervention process for infants with special healthcare needs and their families, the IFSP contains information about the services required to support a child's development and enhance the family's capacity to facilitate the child's development.
individualized health plan (IHP)
A formal mechanism to ensure that the child's health needs are managed in the school setting.
individualized transition plan (ITP)
A plan that focuses on assisting the individual in moving successfully from school and home into other community settings.
medically fragile
Children who need skilled nursing care with or without medical equipment to support vital functions.
normalization
The process of family management that involves acknowledging that the child has a chronic health problem but encouraging the family members to make an effort to lead normal lives.
respite care
A family support service that provides periodic breaks from the constant stress of caring for the child.
technology-assisted
Special services for infants and toddlers up to age 3 years who have developmental delay or are at risk for developmental delay.
transition
Change.
1 . Which nursing intervention is directed towards the school-age child's independent management of asthma symptoms?

1 . Encourage the child to use the flow meter and record results every day.
2. Assess the child and family's level of understanding about asthma.
3. Discuss with the child how to tell friends about asthma.
4. Teach the parents proper use of inhalers.
1. Encourage the child to use a peak flow meter and record results every day.

Rationale: Only encouraging the child to use the flow meter and record results every day is directed toward independent self-care. The other nursing interventions are all important, but they do not address the child's independent management of symptoms. Cognitive Level: Application; Client Need: Physiological Integrity; Nursing Process: Implementation; Learning Outcome: Assess the child with a chronic condition and identify specific nursing interventions for the child at different ages.
2. The nurse is planning a checkup visit for an adolescent with a chronic condition. The nurse should include which topic of anticipatory guidance?

1 . The adolescent will perform many self-care activities.
2. The adolescent with a chronic condition may be more likely to withdraw from social activities and relationships.
3. The parents should begin to describe the long-term needs in terms the child can understand.
4. The parents should always allow the adolescent choices to promote autonomy.
2. The adolescent with a chronic condition may be more likely to withdraw from social activities and relationships.

Rationale: Adolescents do not want to stand out from their peers so those with obvious differences are more prone to withdraw. Adolescents may be physically capable of performing them but are likely to ignore those self-care activities to fit in with their peers. It is appropriate anticipatory guidance for parents to use terms the child can understand for school-age children, not adolescents. Having the parents allow choices to promote autonomy is appropriate anticipatory guidance for toddlers, not adolescents. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning; Learning Outcome: Assess the child with a chronic condition and identify specific nursing interventions for the child at different ages.
3. The family of a hospitalized child with leukemia believes the child will be cured by prayer alone, and plans to take the child home. Which nursing intervention will address this barrier to care?

1 . Demonstrate respect for the family's wishes.
2. Evaluate the home for wheelchair accessibility.
3. Communicate the parents' request to the child's physician.
4. Assess the family's understanding of leukemia.
4. Assess the family's understanding of leukemia.

Rationale: A child with leukemia has a life-threatening chronic condition that requires ongoing nursing and medical care. The nurse first must assess if the family understands the gravity of the child's condition and required treatment.Assessment ofthe situation must take precedence over evaluation of wheelchair accessibility. Although the physician needs to know ofthis request, it is more important to assess the situation first so the physician can be aware of the family's exact situation. Demonstrating respect is important, but the nurse must first ensure the family understands their child's diagnosis and possible outcomes. Cognitive Level: Analysis; Client Need: Psychosocial Integrity; Nursing Process: Implementation; Learning Outcome: Assess the family of a child with a chronic condition and discuss the impact ofthe child's condition on the family.
4. Which outcome indicates a successful transition from hospital to home for the family of a 2-year-old child with a tracheostomy due to bronchopulmonary dysplasia?

1 . The parents demonstrate proper technique of suctioning the tracheostomy in the hospital.
2. The child demonstrates self-care skills prior to discharge.
3. The family provides appropriate home care for the child while maintaining family routines.
4. The parents demonstrate how to take the child's vital signs at home.
3. The family provides appropriate home care for the child while maintaining family routines.

Rationale: Maintenance of family routines while successfully caring for the ill child is the only answer that addresses the hospital-to-home transition. The child is too young to do self-care. Suctioning the child's tracheostomy and taking vital signs are skills required ofthe parents before discharge, but performance ofskills does not indicate that the parents will successfully navigate the transition to home care. Cognitive Level: Analysis; Client Need: Psychosocial Integrity; Nursing Process: Evaluation; Learning Outcome: Assess the family of a child with a chronic condition and discuss the impact ofthe child's condition on the family.
1. A parent tells the nurse, "I just don't think my child will make it this time. We have had so many hospitalizations, but this time is different." This statement is consistent with which nursing diagnosis?

1. Anticipatory Grieving related to child's deteriorating health status
2. Knowledge Deficit related to complex condition management plan
3. Compromised Family Coping related to prolonged condition management
4. Risk for Impaired Parenting related to stress with many hospitalizations
1. Anticipatory Grieving related to child's deteriorating health status

Rationale: The parent is preparing for the worst outcome and expresses an intuition. There is no behavioral evidence of problems with family coping, deficient knowledge, or impaired parenting.
2. A mother confides to the nurse that she gets so frustrated at times that she is afraid that she will hurt her child, who is mentally and physically challenged. The nurse makes which nursing diagnosis?

1. Compromised Family Coping related to caregiver burnout.
2. Caregiver Role Strain related to child's chronic condition.
3. Risk for Impaired Parenting related to feelings of anxiety.
4. Fatigue related to excessive role demands in caring for child.
3. Risk for Impaired Parenting related to feelings of anxiety.

Rationale: The mother states that she fears she will harm her child because she is frustrated, which is subjective data. She has not actually harmed the child; thus, she is at risk for harming the child. There are no subjective or objective data to support the other nursing diagnoses.
3. Which nursing intervention is most important for the family of a premature infant of 16 weeks' gestational age with Down syndrome who is not expected to survive?

1. Orient the parents to the high-tech environment of the neonatal intensive care unit.
2. Refer the family to social services to receive assistance for respite care.
3. Encourage the parents to join the hospital's support group for children with Down syndrome.
4. Support the family in anticipatory grieving.
4. Support the family in anticipatory grieving.

Rationale: A family with a child who is not expected to live will experience anticipatory grieving. Referral to social services and a support group assume that the child will be discharged. Orientation to the unit is not a priority nursing intervention over supporting the family in anticipatory grieving.
4. Which of the following indicates that a 10-year-old girl with diabetes has achieved an expected outcome for the nursing diagnosis of Knowledge Deficit (child) related to learning self-care skills?

1. The child demonstrates correct technique of withdrawing insulin from the vial.
2. The child verbalizes fear in giving injections to herself.
3. The child asks her parents to check her blood sugar.
4. The child participates in a diabetes support group.
1. The child demonstrates correct technique of withdrawing insulin from the vial.

Rationale: Correct technique of insulin withdrawal is an observable behavior that shows that the child has learned a self-care skill for her diabetes. The other answers are behaviors but are not related to a knowledge deficit of self-care skills.
5. A child with cerebral palsy might be at high risk for neglect and abuse. Which of the following nursing diagnoses address this risk? (Select all that apply.)

1. Caregiver Role Strain related to continuous responsibilities for caring for child.
2. Increased Parental Stress related to inadequate social support.
3. Risk of Impaired Parenting related to child's care requirements.
4. Ineffective Family Coping related to inadequate financial resources.
5. Risk of Parental Anxiety related to concerns of child's future.
3. Risk of Impaired Parenting related to child's care requirements.
5. Risk of Parental Anxiety related to concerns of child's future.

Rationale: "Risk of/for" nursing diagnoses are those that might happen given the client's condition, medical diagnosis, and family circumstances. The other answers are actual nursing diagnoses that must be supported by objective or subjective data from a specific family situation.
6. A 2-month-old infant is hospitalized for surgical repair of a cleft lip and palate. Priority nursing interventions include:

1. Refer the family for enteral nutrition equipment.
2. Assess the parents for parental-infant bonding.
3. Teach parents to provide a safe home environment.
4. Provide information about the recommended immunization schedule.
2. Assess the parents for parental-infant bonding.

Rationale: Parental bonding might be impaired in an infant with a facial defect. Teaching about safety and about recommended immunization schedules is done during well child care visits; these are not priority nursing interventions at this time. Enteral nutrition equipment is not required for this infant.
7. Well child care for a child with sickle cell anemia will include which of the following?

1. No immunizations, because the child is immunocompromised.
2. Additional immunizations, because of the child's higher-risk status for infection.
3. Refer the child for genetic testing.
4. Daily dietary supplemental folate and vitamin B12.
2. Additional immunizations, because of the child's higher-risk status for infection.

Rationale: All children with chronic conditions should receive additional immunizations appropriate for their higher risk status for infection. Genetic testing of the child is not needed at this time; parents should be tested for sickle cell and sickle cell trait. Daily dietary supplements of folate and B12 are not necessary for sickle cell anemia.
8. The family of a hospitalized child with leukemia believes that the child will be cured by prayer alone and plans to take the child home. Which of the following nursing interventions will address this barrier to care?

1. Assess the family's understanding of leukemia.
2. Demonstrate respect for the family's wishes.
3. Evaluate the home for wheelchair accessibility.
4. Communicate the parents' request to the child's physician.
1. Assess the family's understanding of leukemia.

Rationale: A child with leukemia has a life-threatening chronic condition that requires ongoing nursing and medical care. The nurse first must assess if the family understands the gravity of the child's condition and required treatment. Demonstrating respect for the family's wishes does not protect the child's life.
9. Which nursing intervention is directed to the school-age child's independent management of asthma symptoms?

1. Encourage the child to use his flowmeter and record the results every day.
2. Discuss with the child how to tell friends about asthma.
3. Assess the child and family's level of understanding of asthma.
4. Teach the parents the proper use of inhalers.
1. Encourage the child to use his flowmeter and record the results every day.

Rationale: Only encouraging the child to use his flowmeter and recording results every day is directed toward independent self-care. The other nursing interventions are all important, but they do not address the child's independent management of symptoms.
10. Which outcome indicates a successful transition from hospital to home for the family of a 2-year-old child with a tracheostomy due to bronchopulmonary dysplasia?

1. The parents demonstrate how to take the child's vital signs at home.
2. The child demonstrates self-care skills prior to discharge.
3. The parents demonstrate proper technique of suctioning tracheostomy in the hospital.
4. The family provides appropriate home care for the child while maintaining family routines.
4. The family provides appropriate home care for the child while maintaining family routines.

Rationale: Maintenance of family routines while successfully caring for the ill child is the only answer that addresses the hospital-to-home transition. The child is too young to do self-care. Suctioning the child's tracheostomy and taking the child's vital signs are skills required of the parents before discharge, but performance of skills does not indicate that the parents will successfully navigate the transition to home care.
What education would you provide to a group of classmates with regard to the reentry of a child with a chronic condition?
Educating classmates of a child with a chronic condition is not directly addressed in the textbook hints. The grade, age, and developmental level of the classmates are variables that the nurse must consider. By reflecting on the child's responses to entering school, such as fears of embarrassment and nonacceptance, the nurse can encourage classmates to empathize with the child. The nurse can prepare classmates for any changes in the child's physical appearance, energy level, and social needs. Thus, any plan for school reentry should include classmates as well as school administrators, teachers, and parents.
Refer to Haley, the 8-year-old girl with cerebral palsy, discussed at the beginning and the end of the textbook chapter to answer the following questions:
...
What are Haley's health promotion and maintenance needs before she begins school?
Haley, along with her siblings, has the same health promotion maintenance needs of good nutrition and proper stimulation for growth and development. Well child care before school entry also includes laboratory screening tests, dental hygiene, and immunizations.
How can the school nurse assist with the individualized education plan (IEP) and individualized health plan (IHP)?
The school nurse must collaborate with the clinic nurse and other healthcare team members to complete an IHP. Based on the IHP, the school nurse can advocate for Haley in IEP meetings. For example, the IHP might offer information supporting the necessity of computer-assisted learning devices for Haley. The school nurse is in a crucial position to coordinate the integration of Haley's IHP and IEP.
How will the school nurse know that Haley and her family have made a successful transition from home to school?
Expected outcomes for a successful transition from home to school for Haley and her family might include:

Haley says, "I have made new friends."
Haley's teacher reports that her classmates have included her in all activities.
Haley's mother expresses less worry about the transition and enjoyment with some respite time.
Haley's sister does not express jealousy or anger about Haley's attending the same school.
Emma, a 3-year-old, has had asthma since she was 12 months old. She knows how to use her flowmeter, and her asthma is well controlled with an inhaler.
...
Is Emma able to use her inhaler independently in preschool?
Preschoolers have the manual dexterity to use an inhaler but not the cognitive ability to decide when to use the inhaler based on asthma symptoms.
On a cold day, Emma develops dyspnea and wheezing while running during outside playtime. The teacher brings Emma inside to the nurse. Emma asks the nurse if she was being "bad." What should the nurse say?
Preschoolers engage in magical thinking and might believe that their behavior causes symptoms or that their symptoms are a punishment for bad behavior.
What could the nurse encourage Emma to do for show-and-tell in her classroom?
The nurse could encourage Emma to bring in her flowmeter and show the other children how she uses it. This will give Emma a positive feeling of achievement, reinforce self-care, and educate her peers.
Ian, a 14-year-old boy, has Hodgkin's lymphoma, and has missed a year of school due to chemotherapy treatments. He will start school again in September, but he now is in a new class one grade behind his peers. As side effects of chemotherapy, Ian has lost his hair, and his puberty has been delayed.
...
What can the school nurse do to promote Ian's transition to a new class?
Adolescents often are self-absorbed and might not reach out to a new person who looks different from them. Ian's transition can be facilitated by a caring nurse who has a frank education session with the class before Ian's arrival.
What can the school nurse do to promote Ian's transition to a new class?
Maintaining ties to old friends is essential to Ian's well-being. The school nurse can incorporate time with former classmates into Ian's individualized health and educational plans as tutors or during lunchtimes.
What can the school nurse do to help Ian protect his health as he adjusts to the school setting?
The school nurse has an important role in monitoring children and adolescents with any chronic condition. Ian must be careful to build his immune system by eating nutritiously and getting adequate rest, sleep, and exercise, but not becoming exhausted. The nurse can encourage Ian's friends to watch out for him.
The school nurse should be watchful to prevent what kinds of behavior in Ian and his peers?
Some adolescents turn to risky or acting-out behaviors as a way of coping with stressful situations, changed body image, or fears of underachievement. The nurse can seek out Ian for discussions about his transition to school. The nurse should be alert for signs of substance abuse, depression, aggressive behavior, and unprotected sexual activity in any adolescent.
Chapter 22: End-of-Life Care and Bereavement
...
■ One commonly accepted definition of death in the United States is brain death, or the irreversible cessation of all functions of the brain, including the cerebral cortex and brainstem.
...
■ Children may experience loss through death of a parent, sibling, grandparent, pet, or friend, and through losses associated with relocation, trauma, and loss of an object.
...
■ The child's developmental level, culture, spirituality, and parental support directly affect the child's response to loss, death, and grief.
...
■ Grief is individualized. Not everyone dealing with a loss will experience all of the stages (denial, anger, bargaining, depression, and acceptance), and individuals who do experience all stages may not experience them in the sequence listed.
...
■ Palliative care combines therapies to comfort and support persons with a short life expectancy, by providing therapies to improve the quality of remaining life.
...
■ The families of dying children face many decision-making issues such as palliative and/or hospice care, advance care planning, the withholding or withdrawal of treatments, and DNR requests.
...
■ Children with life-threatening illnesses often learn about death and their own illness through exposure to other ill and dying children. Even if they have not been told they are dying, they will know their condition is worsening with extra treatments, feeling ill, and cues from their parents.
...
■ It is essential to work closely with the family when a child's death is imminent, helping to provide the support and services most important to them in the last moments or hours of their child's life.
...
■ The nurse caring for the dying child and family offers physiologic and psychosocial support during end-of-life care.
...
■ Bereavement support must be provided to the family, making sure that siblings are not overlooked. Allow siblings to participate in planning the memorial service. Encourage parents to allow siblings to express their emotions.
...
■ Caring for a dying child is difficult, and nurses need special preparation to meet the needs of the child and family while managing their own personal stress.
...
CRITICAL THINKING IN ACTION
Zachary Conway is a 3 1⁄2-year-old who began experiencing motor difficulties and demonstrating bizarre emotional behavior a few months ago. After a series of diagnostic studies, he was diagnosed with an inoperable, rapidly progressing brain tumor. Zachary underwent radiation and chemotherapy to reduce the size of the tumor. He is currently hospitalized after experiencing grand mal seizures and dehydration from poor oral nutritional intake. Zachary's condition has deteriorated and his death is imminent. Emphasis is now on promoting his comfort and supporting his family during the death vigil. Zachary is awake but appears lethargic. He now receives enteral feedings, fluids, and pain medication via a nasogastric tube. He interacts very little with anyone other than his mother. Zachary's mother remains with him at all times during hospitalization while other family members visit. His father spends several hours each day at the hospital. Zachary's sister, Marilee, attends school in the second grade. She is being cared for by grandparents after school when her mother and father are with Zachary. What is the role of the nurse in caring for Zachary and his family? What nursing interventions address the physiologic and psychological needs of the child who is dying? How can you provide family-centered care?
...
INTRODUCTION
Recall Zachary, the 3-year-old child with an inoperable brain tumor hospitalized and near death. His seizures and dehydration are being treated. He is also receiving morphine for pain. His mother remains at his bedside while his father and other family members visit.
...
DESCRIPTION
Despite aggressive therapy, Zachary's condition has continued to deteriorate. After consulting with Zachary's healthcare team, the parents agree to discontinue the radiation and aggressive treatment. He will continue to receive antiseizure medications, pain medication, and nutrition. They have requested a DNR order and the family wishes to have time with Zachary to say good-bye. The parents want guidance to help Zachary's 7-year-old sister Marilee say good-bye.
...
DISCUSSION
1 . What role does the hospital nurse play in facilitating end-of-life care for Zachary?
The nurse:
- Works with others on the healthcare team to plan nursing care that matches Zachary's physical, cognitive, emotional, and spiritual level of development.
- Implements family-centered care, ensuring that Zachary's family is part of the care team and that their beliefs, feelings, and desires are respected.
- Plans and provides compassionate care for Zachary and his family through death and bereavement, or provides good hand-off information if Zachary's care is done at home or another setting.
- Seeks information (research/evidence), education, and mentoring to provide optimal end-of-life care to Zachary and his family.
2. Based on Marilee's developmental level, what is her understanding of Zachary's imminent death? What nursing interventions should be offered to help her say good-bye?
Marilee is in the cognitive, concrete operational stage. She understands the difference between temporary separation and death. She understands that death is permanent. She may have magical thinking that needs exploration and clarification, e.g. belief that death is a person like a grim reaper. She may have guilt if she has been resentful of the time the family has spent with Zachary since diagnosis. She may not realize that death can occur at any age (such as for her 3 year old brother). Nursing interventions include working with others on the team (such as child life specialist) to listen to her fears and answer her questions about her brother's care, visit the bedside of her brother, and create memories of her brother. Nurses (and others) will prepare Marilee to how her brother will look as his condition worsens, and what he will look like when he dies. She will be assisted to be at the bedside to talk to her brother and ask questions, participate in music/singing/spiritual rituals at the bedside, if desired by her parents. Marilee can be offered activities to help keep her brother's memory alive and say her goodbyes: art activities (creating a book for Zachary or a memory book about Zachary and her relationship for herself/family), planting a special plant (or creating a special planter).
3. What are the physiologic signs indicating that Zachary is approaching death?
Signs include:
a. Cardiovascular: heart rate will decline, blood pressure will decline , color will become motteled, cyanotic; extremities will be cool
b. Respiratory: air hungry appearance with increased work of breathing; gasping; cheyne-stokes respirations (shallow breathing with apneic pauses; may have increased secretions and gurgling
c. Neurological: decreased level of consciousness; may be agitated or restless
d. Other organs: progressive musculoskeletal weakness; renal perfusion decreases until there is no urine output; GI perfusion decreases, motility decreases leading to lack of toleration of enteral intake
4. Develop a family-centered nursing care plan for Zachary's end-of-life care.
See #5
5. Develop a family-centered nursing care plan for Zachary's family during end-of-life care.
Nursing dx and interventions will be designed for Zachary including:

a. Promotion of pain management/comfort
- Pain assessment using developmentally appropriate tool, e.g. FLACC to assess/evaluate medication and comfort measures
- Administer pain medications/sedatives titrated to optimal comfort goal
- Position Zachary so that his respiratory efforts are optimized; suction (and/or medicate) if he has increased secretions.
- Utilize other comfort measures designed by family, e.g. have family member rock or hold Zachary (or lay in the bed with him); massage, music, low lighting, etc.

b. Assisting child for a peaceful death
- If he is alert and able to participate, help family talk to him about death in terms a 3 year old understands. Often times, child life specialists have books/stories that help a 3 year old understand what to expect.
- Help family have private time with him
- Create a peaceful environment once child is no longer to enjoy activities due to physiological/mental status. If possible, dc monitors (or lower the alarm volume), decrease lighting, utilize music)

c. Assisting the family to provide comfort and care for Zachary
- Assist with planning rituals or providing environment for spiritual care.
- Help family plan/implement comfort measures for Zachary, e.g. time with him at the bedside, holding, rocking him; watching movies, reading books to him, etc.

d. Assist the family to cope with Zachary's impending death
- Let the family know what to expect as Zachary's physical status declines and death is imminent and answer questions for them
- Coordinate/ communicate with chaplain, social worker, outside clergy/community resources to have them assist family with their feelings, planning for memorial service/remembrance of Zachary, creating a website for communication re. Zachary's status/journey (such as through caringbridge.org).
- Listen to their memories, desires, grief; assist with praying or rituals that are helpful to them
- Encourage them to let others help them....food (or subsidized meals in hospital), setting up sleeping arrangements, including space for one parent at the bedside

e. Assist to set up follow-up for family after child's death
- Connect them to available resources, which may include hospice/grief support groups, e.g Candlelighters support group (oncology pts); special resources for Marilee (support group, camps, counselor, etc).
Air hunger
The most severe form of dyspnea.
Anticipatory loss
The anticipation of loss experienced before the loss actually transpires.
Anticipatory mourning
Grief occurring before an expected loss in anticipation of that loss.
Bereavement
The situation of having experienced loss through the death of a loved one.
brain death
The irreversible cessation of all functions of the brain, including the cerebral cortex and brainstem.
Cheyne-Stokes respirations
Periods of shallow breathing alternating with apnea, a sign of imminent death.
Complicated grief
An unhealthy grief that is not resolved; the grief is intensified to the level that the individual is so overwhelmed that it interferes with ability to function.
death anxiety
A feeling of apprehension or fear of death.
Death imagery
Any reference to death or death-related topics, such as going away, separation, funerals, and dying, given in response to a picture or story that would not usually stimulate a child to discuss death-related topics.
Do Not Intubate (DNI) order
An order written by a physician at the family's request not to intubate a child who stops breathing.
Do Not Resuscitate (DNR) order
An order written by a physician at the family's request not to resuscitate or take other lifesaving interventions for a child who stops breathing.
Euthanasia
The act of someone, other than the patient, ending the life of a patient with a terminal condition to relieve suffering.
grief
An individual's feelings and behaviors in response to death.
heart-lung death
Irreversible cessation of circulatory and respiratory functions.
Hospice
A philosophy of care for a terminally ill child that is focused exclusively on comfort and making sure the remaining time for the child is lived as comfortably and fully as possible.
Loss
When something of value is changed, no longer available, or can no longer be experienced.
Mourning
The behavioral and psychological process of adapting to the loss.
palliative care
An approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention, assessment, and treatment of pain and other physical, psychosocial, and spiritual problems.
1 . Which is the correct developmental stage at which a child begins to have a more realistic understanding of death?

1 . Preschooler
2. Adolescent
3. School age
4. Preteen
3. School age

Rationale: Cognitively after age 6 or so, children are able to understand that death is permanent and occurs from varied causes. Preschoolers have magical thinking and believe death is temporary. Many preschoolers believe that bad thoughts and/or behavior cause death. The understanding occurs during the school-age years. The adolescent understands death much like an adult. There is no developmental stage by the name ofpreteen. Cognitive Level: Application; Client Need: Psychosocial Integrity; Nursing Process: Assessment; Learning Outcome: Apply the child's concept of death and loss to each of these age groups: infant, toddler, preschool, school age, and adolescent.
2. Following a diagnosis of cancer, a child is close to dying. The child asks the nurse what she can do to make sure her family will be okay after her death. Which is the most appropriate response?

1 . "Don't worry about your family, they will be just fine."
2. "I think you should talk to them and tell them what you want for them."
3. "Why are you worried about something you can't control?"
4. "Can I get your family in here for you to let them know your worries?"
2. "I think you should talk to them and tell them what you want for them."

Rationale: The nurse should talk to the child as long as she wants. It is not therapeutic for the nurse to put offthe child by telling her not to worry or asking her why she's worried. Cognitive Level: Analysis; Client Need: Psychosocial Integrity; Nursing Process: Implementation; Learning Outcome: Intervene with the child's responses to his or her impending death.
3. Which is an early indication of impending death?

1. Cheyne-Stokes breathing
2. Hearing loss
3. Increased fluid intake
4. Urine output of 5 mL/hr
4. Urine output of5 mL/hr

Rationale: The kidneys are the first organs to respond with a decrease in function when death is imminent. Cheyne-Stokes breathing is a late sign ofimpending death. Hearing does deteriorate but is considered to be the last sense to diminish before death. Oral intake decreases, and anorexia is common. Cognitive Level: Analysis; Client Need: Physiological Integrity; Nursing Process: Assessment; Learning Outcome: Apply assessment skills to identify the physiologic changes that occur in the dying child.
4. Which is the most appropriate nursing diagnosis for the family of a dying child?

1. Anticipatory Grieving related to terminal illness
2. Parental Role Conflict related to child's hospitalization
3. Interrupted Family Processes related to child with terminal illness
4. Activity Intolerance related to functional changes accompanying the dying process
1. Anticipatory Grieving related to terminal illness

Rationale: Families need to be prepared for the impending death, and nurses should provide this support by discussing the events forthcoming. In a situation involving a dying child, preparing the family for death is the priority. Preparing the family for the impending death takes precedence over the change in family processes. This is not a concern as the child is dying. It is more important to prepare the family for the death. Cognitive Level: Analysis; Client Need: Psychosocial Integrity; Nursing Process: Diagnosis Learning Outcome: Develop a nursing care plan to provide family-centered care for the dying child and his or her family.
5. A home health nurse needs to make a visit to the home of a child who recently died to close the case. How might the nurse best support this family?

1 . Keep the visit short and business-like to keep it as painless as possible.
2. Allow the family to ask questions about the recent events and future expectations.
3. Ask the family what they have been doing since the child died.
4. Send another nurse with whom the family is not familiar to keep it impersonal.
2. Allow the family to ask questions about the recent events and future expectations.

Rationale: Making the visit personal is important to share memories ofthe child as a way to help provide support. The priority support would be for the nurse to let the family lead the conversation, not to ask them questions. Cognitive Level: Analysis; Client Need: Psychosocial Integrity; Nursing Process: Implementation; Learning Outcome: Implement strategies for bereavement support of the parents and siblings after the death of a child.
1. A toddler's grandmother, who cared for him while the parents worked, has died. The nurse recognizes which behavior to be consistent with the toddler's expected response to death?

1. Resists cuddling and cries excessively
2. States belief that the dead person will awaken
3. Complains of a stomachache
4. Complains of trouble falling asleep
4. Complains of trouble falling asleep

Rationale: The toddler might manifest a sense of loss or separation anxiety by having sleep disturbances. Infants resist cuddling, might cry excessively, and might sleep more than usual. Preschoolers believe death is reversible and might think that the dead person will awaken. Older children might have psychosomatic complaints.
2. An adolescent who lost both her parents and her younger brother in a plane crash survived the crash but now is hospitalized after an attempted suicide. She lives with her older brother and his family. The older brother asks the nurse why she attempted suicide. The nurse's best reply is:

1. She is experiencing survivor guilt.
2. She has no understanding of the true concept of death.
3. She has a fear of being abandoned.
4. She might have inherited a tendency for severe depression.
1. She is experiencing survivor guilt.

Rationale: The adolescent feels guilty about surviving the crash that killed her family members. No data support an inherited tendency for depression or a fear of abandonment by her older brother. Adolescents have a true concept of death as permanent and irreversible, whereas younger children do not.
3. The parents of a terminally ill child tell the nurse that they believe their child will not die because they asked God to spare the child if they gave enough money to build a new church. The nurse recognizes that the parents are in which stage of grieving?

1. Bargaining
2. Acceptance
3. Anger
4. Denial
1. Bargaining

Rationale: The parents are bargaining or trying to exchange something for the life of their child. They are not expressing anger or acceptance. They still might be denying the situation, because the stages of grieving are not linear. Bargaining is the best and more complete description of the parents' thinking and behavior.
4. The nurse is about to approach the family of a child who was killed in a bomb explosion about organ donation. The nurse first expresses her empathy for the family concerning their loss. What is the nurse's best opening question to the family?

1. "Have you thought about giving life to other children by donating your child's organs?"
2. "Has any family member ever donated his or her organs?"
3. "Would you consider donating your child's organs?"
4. "Do your religious beliefs allow organ donation?"
1. "Have you thought about giving life to other children by donating your child's organs?"

Rationale: Framing organ donation in terms of the hope it can bring to other children makes a difficult decision more acceptable to parents. The faith of Jehovah's Witnesses forbids organ donation, and organ donation might be a complex issue for people of the Jewish faith. The nurse should refrain from asking about specific religious beliefs and should rely on the parents' wishes.
5. An adolescent waiting for a heart transplant asks the nurse for assistance in planning his funeral in case the heart does not become available. The best nursing intervention is replying:

1. "You are not dying yet."
2. "Why? Do you think you are dying?"
3. "Your parents should help you, not me."
3. "What do you want me to do?"
3. "What do you want me to do?"

Rationale: An adolescent has a true understanding of death and knows the reality of his situation. The nurse must not deny that death is inevitable, or the adolescent's trust in the nurse might be lost. The nurse should be honored to assist the adolescent, support his choices as a way of maintaining control, and refrain from giving the adolescent advice about who should help him.
6. The healthcare team and the family are considering a do not resuscitate order (DNR) for a child with a severe brain injury. Issues they must discuss include: (Select all that apply.)

1. Allowing the child to die with dignity.
2. Potential to cause more suffering if resuscitative measures are implemented.
3. The family's feeling that they are giving up on their child.
4. Keeping the child free of pain.
5. Violating state or federal child neglect laws.
1. Allowing the child to die with dignity.
2. Potential to cause more suffering if resuscitative measures
3. The family's feeling that they are giving up on their child.
4. Keeping the child free of pain.
7. Parents of a newborn with trisomy 18 have decided on palliative care for the newborn. The nurses understand that which of the following nursing interventions are applicable in this case? (Select all that apply.)

1. Administering intravenous hydration only
2. Withholding a DNR order
3. Withholding displays of affection for the newborn
4. Withholding nasogastric tube feeding
5. Withholding cuddling and rocking the newborn
4. Withholding nasogastric tube feeding

Rationale: Trisomy 18 is a genetic mutation that is incompatible with life. The newborn with trisomy 18 who is given palliative care should be comforted by being admired, cuddled, and rocked. Intravenous fluids and nasogastric feedings are withheld. The newborn has a do not resuscitate (DNR) order or an allow natural death (AND) order.
8. An adolescent with metastasized cancer is experiencing chronic pain and asks the nurse for an overdose of morphine to end his life. The nurse is legally and ethically obligated to perform which nursing intervention?

1. Comply with the adolescent's request.
2. Focus on effectively relieving the adolescent's pain.
3. Inform the adolescent's parents.
4. Report the adolescent's request to the physician.
2. Focus on effectively relieving the adolescent's pain.

Rationale: Neither the American Nurses Association or the American Academy of Pediatrics supports active euthanasia. If the child's pain is relieved, then requests for euthanasia usually cease. Thus, the nurse is bound legally and ethically to focus on relieving the adolescent's pain and suffering. The nurse is not required to report the adolescent's request to the parents or physician.
9. A hospice nurse makes an initial visit to the home of a terminally ill child to meet the family members and explore the parents' wishes. Which question should the nurse ask first?

1. "Do you want lifesaving interventions withheld?"
2. "Will you consider a do not resuscitate (DNR) or allow natural death (AND) order?"
3. "How do you feel about interventions that will prolong your child's life?"
4. "What can I do for you and your family?"
4. "What can I do for you and your family?"

Rationale: The nurse first must develop trust and ask an open-ended question to assess the parents' stage of grieving and understanding of the child's condition. All the other questions can be asked at a later time. At the present time, they are too specific and might be too threatening for the parents' stage of grieving or understanding.
10. The nurse is caring for a 12-year-old child with cystic fibrosis in the final hours of life. What can the nurse expect to observe when death is imminent? (Select all that apply.)

1. Incontinence of bowel and bladder
2. Cool and mottled skin
3. Increased hunger and thirst
4. Mental confusion, visions
5. Irregular and shallow respirations
1. Incontinence of bowel and bladder
2. Cool and mottled skin
4. Mental confusion, visions
5. Irregular and shallow respirations
An 8-year-old dying child asks the nurse, "Will it hurt to die?" What is the nurse's best response?
Although the dying process itself is not painful, pain may be present due to other physiological disease processes. Pain is the most feared experience for a dying child and his family. The nurse can assure the child and family that the child will not be in pain, that the child will be kept comfortable.
The parents of a 10-year-old girl who is diagnosed and hospitalized with a terminal brain tumor ask that she not be told she is dying. How can the nurse communicate with this family?
A meeting of the girl's healthcare team and family will assist the family in facing their fears of being truthful with their daughter. Trust is not built on silence. Children of this age will pick up cues that they are seriously ill.
A 17-year-old adolescent boy with stage IV bone cancer and in severe pain is admitted to the hospital and requests a do not resuscitate (DNR) order. The parents object to this and overrule him because he is a minor. Then he asks the nurse for an overdose of his morphine. What should the nurse do?
The nurse can request assistance from the adolescent's physician and other members of the healthcare team in thinking through this situation. Once his pain is under control, the request for an overdose may cease. The nurse can assure the adolescent that he will be kept pain-free and comfortable. The healthcare team must meet with the parents about a DNR order to discuss the best interests of the client.
Zach attended preschool before his illness, and his classmates are asking when he will return. At preschool, Zach made a best friend, Joey, who is especially troubled about Zach. Joey is 4 years old and attends preschool. He is refusing to join in play groups and sits by himself during outdoor play. When the preschool teacher visits Zach and his family in the hospital, she finds that Zach's death is imminent. The teacher asks the nurse for assistance in talking with Joey and the preschool class about Zach. Refer to the case scenario at the beginning and end of the textbook chapter.
...
What recommendations can the nurse provide the preschool teacher about talking with the preschool class?
The preschool teacher must be truthful and must tell the class that Zach will not be returning to their class because he is dying. Because preschoolers cannot cognitively comprehend the permanence of death, they still might expect him to return. They also might fear that they somehow caused Zach's illness, or that they also might become ill and not return to class. These fears should be discussed and allayed, and the teacher must realize that these fears and questions will be repeated many times in this age group. A class project, such as planting a tree in Zach's memory, might help the children as well as Zach's family.
When the preschool teacher talks with Joey, she finds that Joey was angry at Zach the last day he was at school. Joey said, "I told him never come back." What can the preschool teacher say to Joey?
Joey misses his friend and is reacting with sadness, depression, and guilt to Zach's absence at preschool. He may believe that he is the cause of Zach's illness and imminent death because he had bad thoughts and said things in anger to Zach. Preschool-age children must be told repeatedly that they are not the cause of a classmate's illness or death.
After Zach's death, Joey exhibits out-of-control, aggressive behavior. The preschool teacher sends Joey to the school nurse for timeout. How does the school nurse interpret Joey's behavior, and what interventions are appropriate?
Children experience stages of grief after a significant loss. Joey is in the anger stage. Although aggressive behavior cannot continue in the classroom, Joey needs someone to understand his feelings. The nurse could initiate play therapy sessions to encourage expression of anger in a safe environment. Joey's parents should be informed, participate in the play sessions, and help him come to the acceptance stage.