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Ward: Ch 34: Caring for the Child With a Chronic Condition or the Dying Child
Terms in this set (30)
A pediatric nurse advocates for the children's oncology clinic by initiating a fundraising project that will help pay for expansion of the bathrooms to accommodate wheelchairs. The nurse's motivation is in response to an awareness of which of concept?
A. Chronic illnesses of the patients
B. Disabilities of the patient population
C. Handicaps of the patient population
D. Work of the clinic nurse and other staff
This fundraiser is designed to alleviate difficulties due to handicaps, which are limitations that prevent or interfere with a person's ability to carry out tasks or access certain aspects of the environment. A chronic illness is one that persists over time and may or may not lead to activity limitations. Disabilities refer to the limitations that prevent or interfere with a child's ability to perform daily activities. Although the work of the clinic staff may be made easier with the addition of wheelchair-accessible bathrooms, the focus is on the children who are patients there.
As part of therapeutic play for the patients, the pediatric nurse reads a book about children receiving injections. For which age group is this nursing intervention most appropriate?
C. School-aged children
Priority nursing interventions for the preschooler include providing the child with the opportunity to express fears and frustrations. At this age, the use of storytelling and books about the illness may be helpful in providing a nonthreatening approach to the topic. Additionally, the preschooler can express concerns through dramatic play. The nurse can ask the child-life specialist for assistance with methods of expression.
During a pediatric nursing orientation session to a new unit, the child-life specialist is introduced as an important member of the heath-care team. What is an important role of the child-life specialist?
A. Accompany children on their way to procedures
B. Assist with family counseling regarding hospitalization
C. Describe normal growth and development to families
D. Provide opportunities for therapeutic play
Whenever a child has a chronic condition, it is important to involve the child-life specialist. Because the child with a chronic condition often spends significant amounts of time in the hospital, the days can be long and boring. The child-life specialist is an expert in child development and therapeutic play and can assist in diversion activities during procedures, arrange for therapeutic play, or simply let the child take time to play.
The pediatric nurse is familiar with Kübler-Ross's stages of grief. Parents who are feeling guilty and try to find any cause for their child's illness or blame others for the illness are in which stage of grief?
In the bargaining stage, it is common for the family members to ask, "What did I do to make this happen?" It is normal for the family members to bargain with either themselves or with God in hopes that the child's life will be spared. In the denial stage, the parents have feelings of numbness, disbelief, and shock. Acceptance of the child's illness and possible death means that the family or child has made an emotional adjustment to the illness.
The pediatric nurse understands that with a sudden catastrophic loss, family members can experience physical symptoms such as rapid respirations, agitation, nausea, and diarrhea. According to Epperson, which stage of grief are these individuals experiencing?
C. High anxiety
High anxiety is described by Epperson as a time of great stress, with many physical manifestations of emotional upheaval. A nursing assessment of the family member finds agitation, rapid respirations and increased heart rate, irritability, muscular tension, and fainting, along with digestive or bowel changes that may result in nausea and diarrhea.
The pediatric nurse is caring for a child who has been in a motor vehicle collision. The doctor explains to the family that there are serious physical disabilities. The father is upset and states: "I don't know how we will be able to cope. We have two other children. What can we do?" Which response by the nurse is the most appropriate?
A. "Don't worry. You will be able to manage."
B. "Don't worry. You will get through the crisis."
C. "Many parents find the initial news overwhelming."
D. "The doctor can explain it to you again."
A chronic condition, such as a physical disability, can create a threat of the unknown, loss of control, and long-term effects yet to be discovered. The nurse can reassure the family that the initial news of a physical disability can be overwhelming. The nurse should assist the family in developing an ongoing plan of care to meet the child's physical, emotional, and spiritual needs, as well as offer ongoing support and supply resources to help ensure successful coping. Telling the parents not to worry discounts their very real fears. Having the doctor explain the situation again does nothing to provide psychosocial care to the family.
The pediatric nurse providing nursing care for a 12-year-old girl listens as her mother describes her family situation. She states that the patient's 10-year-old sister is asking many questions about the patient's illness. The patient's mother feels that it is best not to talk about the patient with her sister. Which response by the nurse is the most appropriate?
A. "Having a child in the hospital and having another daughter at home must be challenging. Focusing on the future when your child goes home would be best."
B. "It must be challenging to balance the needs of both of your children. Both children need information about her illness and hospitalization."
C. "It must be difficult for you to balance everyone's needs at this time. Doing what you think is best is most important."
D. "You and your husband know your children best. I am sure that you will decide the best way to handle this situation."
The sibling may be affected in ways such as acquiring a decreased sense of self-esteem, receiving less support from parents, exhibiting mood swings, lacking an understanding about the condition, and displaying a negative attitude toward the child's condition. Priority nursing interventions include teaching the parents to maintain familiar routines as much as possible for the sibling. In addition, the nurse can help the parents include the sibling in simple care. It is also important to remind the parents that providing information about the ill child may decrease stress reactions in the sibling.
A 4-year-old girl diagnosed with leukemia will begin palliative care. The 6-year-old brother does not visit often. The parents worry their son will remember his sister as a "sad, thin, child in the hospital" rather than as his playful sister. Which response by the nurse is the most appropriate?
A. "Your son can handle a visit to see his sister with your help because children are emotionally strong."
B. "Your son needs to say good-bye to his sister prior to her death; you should bring him to visit immediately."
C. "Your son will have these sad memories for the rest of his life; therefore, keeping him away is a good idea."
D. "Your son needs preparation about the change in his sister's appearance, but for his own grieving process, he needs to visit her before her death."
Parents often try to protect the dying child by limiting visitation. It is important for the nurse to communicate to the parents that visits from the sibling are important. Kübler-Ross (1983) stated that the child who has been included in the death and mourning process with the family is able to let go in a healthy way. The sibling may be able to write letters or draw pictures for the child as a way of saying good-bye. It is important that the sibling be included in the grieving process and has the opportunity to say good-bye.
The pediatric nurse is caring for an adolescent with cancer. The parents are interested in exploring complementary and alternative (CAM) therapies. Which response by the nurse is the most appropriate?
A. "Be careful; many CAM providers prey on desperation."
B. "CAM therapies have worked well for many cancer patients."
C. "These treatments only provide relief through a placebo effect."
D. "Although many people like CAM, many therapies have not been researched."
CAM therapies are used by many people and include natural products, mind-body medicine, and manipulative and body practices. One controversy surrounding CAM practices is that many of the therapies have not been researched. The nurse wishes to remain supportive of the family while giving objective information. Telling the family that many people do have success with CAM but advising them that many modalities have not been researched accomplishes both objectives. The other statements either may scare, discourage, or not provide information to the family.
The pediatric nurse attends a debriefing session following the death of a young child who was hospitalized for several months with cancer. The nurse developed a strong relationship with the child and even worked overtime to care for the child. The nurse now describes feelings of sadness, insomnia, fatigue, helplessness, and frustration. Which type of suffering is this nurse experiencing?
B. Compassion fatigue
C. Family empathy
D. Moral distress
Burnout is a state of physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations. It emerges gradually and is a result of emotional exhaustion and job stress. The nurse who is experiencing a severe stress reaction like burnout can seek professional help and participate in a support group to replenish or maximize effective coping strategies.
A nurse notes that a patient with cystic fibrosis develops difficult breathing. The nurse calls the father to report his condition. The father, who has been continually present, cannot be there because the patient's sister has influenza and the father stayed at home to care for his daughter. In the morning, the nurse sees the patient's father and approaches him to talk. Which statement by the nurse is most appropriate at this time?
A. "I feel sorry that you were not here when your son got so sick last night."
B. "Please sit down. I want to update you about your son's condition."
C. "Your son had a difficult night. It is too bad you were not here with him."
D. "Your son might die. Come with me now and see him before it's too late."
The nurse's response should be supportive and caring and should not make the father feel guilty for taking care of his other child. The nurse can help families meet emotional and spiritual needs by offering ongoing support and supplying resources to help ensure successful coping. The nurse caring for the family must remember that uncertainty and fear about the future is a constant worry for the parents of a chronically ill child.
A child with a severe, chronic illness is hospitalized and the staff finds it difficult to deal with the mother, who is overbearing and controlling. What action by the nursing manager would be most appropriate to help the situation?
A. Ensure consistent caregiver staffing.
B. Explain that the mom is trying to regain control.
C. Request a social work consultation.
D. Set strict limits on the mother's behavior.
Although the mother is trying to regain some control over her child's situation, merely explaining this fact won't do much to alleviate the situation. The best outcome is a trusting relationship between caregivers and the mother. Once this is established, the nurses can work with the mother to allow her control when feasible. A social work consultation may be helpful but is not the best answer. Setting limits on the mother's behavior in the absence of a trusting relationship is likely to provoke her and make the behaviors worse.
An infant has been hospitalized since birth. What nursing intervention takes priority for this child?
A. Keeping the parents updated every day
B. Maintaining a set visiting schedule for family
C. Providing a soft crib and cuddly toys
D. Soothing and providing physical touch
Priority nursing interventions for the infant with a chronic condition or undergoing a long hospitalization include measures to provide soothing and physical touch, such as cuddling, holding, using a soft voice, and rocking. Keeping parents up to date is important for any hospitalized child and is not specific to parents of this age group. Visitation should be liberal, preferably 24 hours a day. Soft mattresses and plush objects in the crib increase the risk of sudden infant death syndrome and should be avoided.
A nurse has to perform a brief procedure on a toddler. What action by the nurse is the most developmentally appropriate for this patient?
A. Demonstrate the procedure on a stuffed animal.
B. Offer a choice as to when the procedure is done.
C. Perform the procedure with no advance explanation.
D. Tell the child about other kids who had this done.
Nurses can communicate with toddlers using toys. Demonstrating the procedure on a stuffed animal helps relieve fear. The other options are not appropriate for this age group.
A preschool-age child with a chronic condition is brought to the clinic for a checkup. During the visit she throws things, yells at her mother, and attempts to hit the nurse. The mother sighs and says "I'm afraid yelling at her will make her sicker." What response by the nurse is the most appropriate?
A. Explain that without limits, preschoolers do not feel secure.
B. Inform the mother that she needs to institute some discipline.
C. Re-educate the mother on the progression of the child's illness.
D. Tell the mother that yelling at the child will not make her sick.
Preschoolers need set limits in order to feel secure in their world. This mother needs to set limits on her child's behavior, but the nurse needs to explain the reasoning behind it. Simply telling her to institute discipline will likely make the mother feel criticized. Re-educating the mother may need to occur, but is not the best response to this situation. Telling the mother that yelling will not make her daughter worse does not give the mother needed information.
The parents of a chronically ill 8-year-old do not want him to go outside and play or to attend his friends' birthday parties for fear he will become ill. What response by the nurse is most appropriate?
A. "Can you let one or two friends come over to play?"
B. "Children his age need to maintain friendships."
C. "He can go outside if he wears a mask all the time."
D. "You are right to be concerned that he will get sick."
Although the parents do have to be vigilant that a chronically ill child does not acquire an acute community-based illness, maintaining peer relationships at this age is important. If the parents are unwilling to let the child attend larger gatherings or play outside, the nurse should assess if they would be willing to host smaller play dates. Information about the importance of friendships is a key aspect of working with the parents, but does not offer any solutions. The child may or may not need to wear a mask. Recognizing the parents' concerns is important, but, again, does not give them information or possible solutions.
A teenager with a chronic medical condition requiring frequent hospitalizations has the nursing diagnosis of impaired self-esteem. Which action by the adolescent best indicates that outcomes for this diagnosis have been met?
A. Complies politely with hospital rules and routines
B. Makes choices as to when to bathe or eat meals
C. States understanding of the need for hospitalization
D. Uses social media sites to maintain contact with peers
A teenager's self-esteem is closely linked to acceptance by his or her peer group. Maintaining relationships is vital for healthy adolescent development. The teen using social media when unable to spend time in person with friends shows adaptation to circumstances and a positive action to maintain normalcy. Complying with hospital rules and/or stating an understanding of the need for hospitalization do not mean that the teen's self-esteem has improved. Giving a teen choices when possible helps the teen maintain some autonomy, but making those choices is not the best indicator that outcomes for this diagnosis have been met.
The parents of a chronically ill child confide in the nurse that they are increasingly frustrated with the ill child's younger sibling, who has become very negative toward the ill child and occasionally even hostile. What response by the nurse is the most appropriate?
A. "She is too young to understand; you just have to wait for this phase to pass."
B. "This is really common, unfortunately; the best you can do is to ignore the behavior."
C. "This is a common reaction by siblings; can she help you with your other child?"
D. "You need to spend more time with the younger child so she doesn't feel left out."
A sibling of a chronically ill child may become negative toward the ill child and occasionally hostile based on the continuous attention the ill child may receive and the attention needed by the healthy child. It is common for children to act out when they are seeking attention or frustrated over a situation.
The nurse is caring for the parents of a chronically ill child, who display chronic sorrow. Which action by the nurse would be most beneficial for this family?
A. Encourage the parents to use resources such as respite care.
B. Help the parents establish a routine for school and bedtime.
C. Offer the parents resources to deal with their grieving.
D. Refer the parents to a community center for counseling.
Chronic sorrow is manifested as periods of episodic grieving interspersed with periods of denial as a response to a chronically ill or disabled child. As the child never becomes well, the parents do not have closure for their loss of a "normal" child. A major nursing intervention the nurse can provide is to help the parents normalize as much of their daily lives as possible. One suggestion is to establish routines for daily activities, such as bedtime rituals or going-to-school routines. The other options could all be helpful but are not as comprehensive.
The nurse is teaching the parents of a child with a severe, chronic condition ways to promote growth and development. Which suggestion by the nurse is the most appropriate?
A. Allow interaction with peers, family, and community members.
B. Ensure that the child is getting a nutritious diet and plenty of exercise.
C. Insist that the public school include the child in all activities.
D. Plot the child's growth and weight gain on growth charts monthly.
Although chronic illness can have a negative impact on growth and development, so can the reactions of the child's parents or guardians. Although they need to maintain realistic expectations, parents should ensure that the child has the ability to develop in all areas: physical, cognitive, social, and psychological. The best way to ensure this development is to allow the child interaction with others and provide opportunities for appropriate activity. A nutritious diet is important but only considers the physical aspect of growth and development. It should not be necessary to insist that the school include the child in activities, as this is a legal requirement. Plotting growth is also important, but monitoring the situation is not the same as providing opportunities.
A nurse wants to participate in community service by providing education on the leading causes of death for various age groups coupled with appropriate preventative measures. When discussing deaths in teenagers, which topic does the nurse focus prevention on?
A. Appropriate prenatal care
B. Exposure to carcinogens
C. Genetic testing
D. Violence and injury prevention
The leading causes of death in adolescents are accidents, homicide, suicide, and cancer. Preventative measures directed toward violence and injury prevention would have the greatest impact. Prenatal care and genetic testing would most affect the death rate in infants, the leading causes of which are prematurity and congenital defects. Decreasing exposure to carcinogens might have the greatest impact on school-age children, in whom the most frequent cause of death is cancer and accidents.
A nurse is working with a school-age child who is dying. The child is hostile and uncooperative. Which action by the nurse is the most appropriate?
A. Ask the child what she knows about what is wrong with her.
B. Give the child time to herself and then return to complete tasks.
C. Offer the child a reward for cooperative or pleasant behavior.
D. Tell the child to cooperate with treatments in order to get better.
School-age children often know and understand more than parents want to believe. Attempting to shield the child in this age group from the realities of his or her condition can create an atmosphere of distrust. An angry and uncooperative child often is displaying that distrust. The nurse should open up a conversation with the child and find out what she already knows (or thinks she knows) about her condition. This can help create trust. The child may need some time alone, but this by itself will not improve the situation. Rewards for good behavior may be helpful, especially if the parents use this technique at home, but, again, this is not the best answer. Simply telling the child to behave is not likely to be helpful.
A nurse is caring for a dying child. What intervention by the nurse would be best to promote hope and peace in the family?
A. Ask the family to participate in providing physical care.
B. Ensure the family members eat so they maintain their strength.
C. Help the family members arrange child care for their other children.
D. Tell the family members what is possible for them to do as the child dies.
Everyone needs something to hope for, even if that hope is for a good death. Giving the family options based on what is actually possible helps them maintain some sense of control and allows them to provide caring measures they feel are important. They may or may not want to participate in providing physical care. They may or may not want other siblings present as the child dies. They may or may not want to eat at particular times.
A nurse is evaluating how well the family of a dying child understands the concept of hospice care in the home. Which statement by the family indicates the need for further instruction?
A. "If she gets short of breath, I will call 911 right away."
B. "It will be great that she can play with her sister at home."
C. "Pain control will be very important even near death."
D. "We should look into respite care so we can get a break."
Once hospice care has been chosen, it is important to not make drastic changes in the care plan, especially as the end of life approaches. Hospice care recognizes that death is part of life and is focused on symptom control and quality of life, not cure. The parent who plans to call 911 for shortness of breath does not understand this concept, nor does he or she understand manifestations of approaching death. The other statements are compatible with hospice care in the home.
A hospice nurse is working with the family of a child who has died. Which statement by the parent indicates that further action by the nurse is needed?
A. "I have not been able to function at work since my son died."
B. "Some days I wonder if I could have done anything differently."
C. "There are times when I still get so angry that this happened."
D. "You know, I have had some pretty good days recently."
Kübler-Ross identified five stages of grief: denial and isolation, anger, bargaining, depression, and acceptance. People do not go through these stages in a linear fashion. It is important also for the nurse to understand that people will have good days and bad days, no matter what stage of grief they are in. However, in each stage, there are warning signs that indicate further action should occur. The inability to function normally is one of these warning signs, and the nurse should ensure the parent has appropriate follow-up.
The nurse caring for infants and children understands that which are the scariest aspects of being hospitalized for a 3-year-old? (Select all that apply.)
B. Being different from peers
D. Punishment in the form of illness
E. Separation from parents
A, C, E
The most frightening aspects of hospitalization for toddlers are pain, anxiety, and separation from the parents. Being different from peers is an issue for older children. Fear that illness is punishment is characteristic of the preschooler.
A nurse is explaining the connection between family caregivers of chronically ill children and illness to a group of nursing students. What information about caregivers increases their risk of becoming ill? (Select all that apply.)
B. Financial worries
C. Lack of sleep
E. Poor eating habits
A, B, C, E
Many caregivers describe their health as poor, and many factors may contribute to poor caregiver health. Some factors include insomnia, depression, poor eating, lack of exercise, lack of the ability to take time off for personal health issues/wellness activities, and financial burdens. All of these issues increase the chances of the family caregiver becoming ill.
An experienced nurse is acting as preceptor to a new graduate and is discussing ways to develop a trusting relationship with the families of children who have chronic or terminal conditions. Which are helpful suggestions by the experienced nurse? (Select all that apply.)
A. Ask if and how the parents would like to participate in care.
B. Do not judge the parents' reactions to the child's condition.
C. Follow the child's home routine while hospitalized, if possible.
D. Treat each child as an individual and do not label the child.
E. Work predominantly with the parents; they will include siblings.
A, B, C, D
There are many ways for the nurse to develop a trusting relationship with the family of a child who is chronically or terminally ill. In addition to the four correct options listed above, the nurse should also remember to include the siblings of the patient whenever possible. Siblings often feel left out and isolated.
A nurse is teaching the parents of a dying child how to recognize impending death. Which manifestations does the nurse tell the parents to expect? (Select all that apply.)
A. Changes in breathing patterns
B. Decreased desire to eat or drink
C. Increased blood pressure
D. Pale, cool skin
E. Restlessness or agitation
A, B, D, E
There are many manifestations of impending death, including changes in breathing patterns, decreased oral intake, pale or cool skin, and restlessness or agitation. Blood pressure will decrease.
A nurse is working in the emergency department when a child who was involved in a motor vehicle crash is admitted. The child is critically injured and, despite heroic efforts, does not survive. The nurse finds the family in the waiting room and several family members are agitated and do not listen to the nurse describe the child's injuries. One family member feels faint and another has vomited. What does the nurse understand about the current situation based on Epperson's theory of grieving? (Select all that apply.)
A. It is important to be patient and identify one person to communicate with.
B. Most of the members are totally dysfunctional and should be sent home.
C. Signs of emotional upheaval and physical symptoms are a result of great stress.
D. The nurse should call security, as some family members may become violent.
E. This family is reacting normally to a catastrophic loss, according to one theory.
A, C, E
According to Epperson's theory of grieving, people experiencing a sudden or catastrophic loss experience the grief process differently than do others. There are six phases to this process: high anxiety, denial, anger, remorse, grief, and reconciliation. This family appears to be in the high-anxiety stage, with physical manifestations. The nurse should be patient with the family, find one person to communicate with primarily, and understand that this is a normal response to a great emotional upheaval. The family is not dysfunctional and should not be sent home. Violence is always a possibility in the emergency department, but the nurse should not assume that these family members will become violent. The family should be moved to a private waiting room if possible to avoid disrupting the rest of the department, but the nurse should act as if this behavior is understandable, not something to be controlled.
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