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Exam 2 ch. 11, 12, 13, 16, 17
Terms in this set (40)
A nurse is educating the parents on how to help their 10-year-old daughter deal with an extended hospital stay due to surgery, followed by traction. Which response indicates a need for further teaching?
A:"I should not tell her how long she will be here."
R:Parents who do not tell their child the truth or do not answer the child's questions confuse, frighten, and may weaken the child's trust in them. The other statements are effective forms of communication.
The nurse is caring for a 13-year-old cystic fibrosis patient. The nurse prepares and verifies several medications and brings them and the medication administration record to the patient's room. The nurse observes that the patient is not wearing an identification band. Which of the following actions is the correct one for the nurse to take?
A:Ask the patient to recall their name and date of birth.
R: If the child does not have an identification band in place, the nurse must first identify the child before administering any medication. A parent should identify a baby or a younger child. Ask an older child his or her name and date of birth or other identifier. There is no need to notify the prescribing physician. Admitting may be called at a later time to obtain a new identification band. Locating another RN to identify the patient is not necessary.
The nurse is caring for a child who has conductive hearing loss. Which of the following is true regarding this type of hearing loss?
A:It is caused by chronic otitis media or other infection.
R:In conductive hearing loss, middle ear structures fail to carry sound waves to the inner ear. This type of impairment most often results from chronic serious otitis media or other infection.
The nurse is educating the parents of a 7-year-old boy, scheduled for surgery, to help prepare the child for hospitalization. Which statement by the parents indicates a need for further teaching?
"It is best to wait and let him bring up the surgery or any questions he has"
R:It is important to be honest and encourage the child to ask questions rather than wait for the child to speak up. The other statements are correct.
A mother asks you if there is any way to prevent acute otitis media. A suggestion you would make to her would be
the frequency of otitis media is reduced in breastfed infants.
R:Acute otitis media tends to occur less often in breastfed than bottle-fed infants, probably because of the more upright position in which they are fed.
The nurse is caring for a hospitalized 8-month-old girl with special healthcare needs. Which intervention would best help this infant grow and develop?
Support parental attachment to the child.
R:Attachment interference may already have occurred due to frequent hospitalizations and multiple therapies and treatments. A basic need of this girl is the development of trust in and attachment to her parents. Since stranger fear and separation anxiety is a developmental norm around 8 months, attachment is critical to provide security. All the other interventions should be used to promote development, but attachment is essential.
The nurse is caring for a child who weighs 47 lbs. The medication ordered for the child has a therapeutic dosage of 3 mg/kg per day. The medication ordered is to be given every six hours. Which of the following is the total number of milligrams of medication the child will receive in one dose?
R:One kilogram equals 2.2 lbs.; therefore, a child weighing 47 lbs. weighs 21.3 kg. For the dosage of 3 mg/kg/day, the child will get 64 mg in a day or 16 mg per dose when given every six hours.
The child has been diagnosed with vulnerable child syndrome. Which statements by the child's parent are associated with the presence of this syndrome? Select all that apply.
"For the first few weeks of his life, he was so yellow I was afraid he would glow."
• "When she was a toddler she developed meningitis and the doctors told me they didn't think she'd make it."
• "She was born with a cleft lip and palat I was so afraid she wasn't getting enough formula."
R:Risk factors for the development of vulnerable child syndrome include newborn jaundice, an illness that the child was not expected to recover from, and congenital anomalies.
The nurse is reinforcing teaching with the caregivers of a child who has had a head injury and is being discharged. Which of the following statements made by the caregiver indicate an accurate understanding of the follow-up care for their child?
"Even if the flashlight bothers him, we will check his eyes."
R: The child's pupils are checked for reaction to light every four hours for 48 hours. If the child falls asleep, he or she should be awakened every one to two hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The caregiver should observe the child for at least six hours for vomiting or a change in the child's level of consciousness. The caregiver should notify the health-care provider immediately if the child vomits more than three times, but if the child vomits once, returning to the care provider immediately is not needed.
The nurse is educating parents of a male infant with Chiari type II malformation. Which of the following statements about their child's condition is most accurate?
"Take your time feeding your baby."
R:One of the problems associated with Chiari type II malformation is poor gag and swallowing reflexes, so the infant must be fed slowly. There is a great risk of aspiration, requiring that the child be placed in an upright position after feeding. The goal of surgery is to prevent further symptoms, rather than to relieve existing ones. Infrequent urination is a problem associated with type I malformations.
A nurse is caring for an 18-month-old girl undergoing traction therapy in a rehabilitation unit. The nurse understands that the girl is in the second phase of separation anxiety when she observes what behavior?
The toddler is quiet, looks sad, and is disinterested in playing.
R:Despair is the second phase of separation anxiety. During this phase the child appears hopeless, depressed, and apathetic. Exhibiting signs of anger and agitation or crying inconsolably all indicate the first phase of separation anxiety called protest. Denial or detachment is the third phase of separation anxiety. The child uses this to protect against further emotional pain. When parents return the child will ignore them and, instead, has formed superficial relationships with other caretakers. This third stage is seen infrequently when family-centered care is in place.
The mother of a 12-year-old with Reye syndrome approaches the nurse wanting to know how this happened to her child, saying, "I never give my kids aspirin!" What could the nurse say to begin educating the woman?
"Sometimes it's hard to tell what products may contain aspirin."
R: Salicylates are in a wide variety of products, so consumers must read the small print very carefully or they will miss the warning. The parent needs to be receptive to further education, and raising the possibility the child was responsible does not accomplish that goal. Don't state the obvious, but also don't minimize the situation. Encouraging the mother to ask for information and offering explanations in terms she will understand are important, but this response does not address the mother's assertion
The nurse is preparing to administer a PO medication to a 6-year-old patient in the hospital for an exacerbation of asthma. The nurse notes that the patient is due for an oral dose of Prevacid in one hour. Which of the following is the most important action for the nurse to take before administering this medication to the patient?
Clarify the order, since there is no apparent link between the patient's diagnosis and the medication.
There is no clear link between this patient's diagnosis and the Prevacid medication. The nurse should clarify a medication order that does not have a clear link to the patient's diagnosis before giving the medication. Asking the mother how she usually gives the medication is a good idea; however, it is not the priority nursing action in this scenario. Parental permission is not required to administer this medication. Consent to treat is signed upon admission to the hospital.
A 15-year-old boy with special needs is attending high school. Which nursing intervention will be most beneficial to his education?
Serving on his individualized education plan (IEP) committee
R: Serving on his individualized education plan committee will be most beneficial to his education because this plan is designed to meet his individual educational needs. Collaborating with the school nurse and assessing the health effects of attending school, and getting a motorized wheel chair do not address his educational needs.
A child is diagnosed with bacterial meningitis. The nurse would suspect which abnormality of cerebrospinal fluid (CSF)?
In the CSF of clients diagnosed with bacterial meningitis, the pressure is elevated, the appearance is cloudy, and the leukocytes are elevated. A decreased sugar content is noted.
A nurse is assessing a child's vision. Which test should she use to test for accommodation?
Moving a penlight toward the client's nose and observing whether his eyes can follow it
R:To test for accommodation, ask a child (over 6 months of age) to follow a penlight as you move it in toward the nose. Children who cannot accommodate are unable to fuse their vision to follow a penlight toward their nose this way; instead, they demonstrate double vision (diplopia). The Stereo-Fly dot test, a test where the image of a fly is constructed from a series of colored dots, is used to test stereopsis. When asked to touch the fly's wings, a child with good depth perception touches them accurately. A child with poor depth perception touches a spot 2 or 3 inches above the pattern. Hirshberg's test is used to detect true strabismus. The Weber test is a test for hearing.
A nurse is developing a preoperative plan of care for a 2-year-old. The nurse should pay particular attention to which of the child's age-related fears?
Separation from parents
A toddler is most likely to develop anxiety and fears due to separation from the parents. Separation from friends, loss of control, and loss of independence are fears typically experienced by an adolescent
The nurse is admitting a 14-year-old girl for a tonsillectomy and is preparing her for the procedure. Which of the following is the best statement or question?
"Are you wondering about anything related to your tonsillectomy?"
For a 14-year-old girl, the best approach would be to ask an open question so that concerns, lack of understanding, or a need for information can be determined. Asking if the teen feels "scared" may get a "yes" or "no" response, which may or may not be honest depending on what the teen expects of herself or believes others expect of her. An adolescent is often reluctant to admit fear. Mentioning scary hospital sounds provides no information and is inappropriate developmentally. Introducing discharge instructions needs to come later after other needs are met. Some discharge information is covered during admission since tonsillectomy is usually day surgery
The nurse is educating the parents of a 4-year-old boy with strabismus. Teaching for the parents would include the:
Importance of patching as prescribed.
Teaching the parents the importance of patching the child's eye as prescribed is most important for the treatment of strabismus. The need for ultraviolet-protective glasses postoperatively is a subject for the treatment of cataracts. The possibility of multiple operations is a teaching subject for infantile glaucoma. Teaching the importance of completing the full course of oral antibiotics is appropriate to periorbital cellulitis.
While working in the emergency room, the nurse receives a call that a 3-year-old child sustained extensive burns in a house fire. Assuming all of the following actions are included in the standing burn-care protocol, which action should be the nurse perform first?
Obtain a weight
Obtaining a weight provides a base for calculating the fluid that will need to be replaced. NG placement and/or drinking milk are not actions to take at this point. Tetanus can be given later and is not critical to active management.
A 5-year-old is diagnosed with acute otitis media. Which nursing intervention below would be a primary one?
Relief of pain
R:Acute otitis media is painful. Children need pain relief until the antibiotic also prescribed reduces the inflammation and pressure.
An infant with poor eye alignment cannot establish single binocular vision but has double vision. The nurse knows that another term for this disorder is which of the following?
R:Diplopia is another name for double vision. Stereopsis is depth perception or the ability to locate an object in space relative to other objects. Myopia is nearsightedness. Hyperopia is farsightedness.
Which of the following assessment is the most important for determining an accurate dose of a pediatric medication?
Body surface area
R:Body surface area (BSA) is the most accurate measure for dosing medications for children. In pediatrics, there are no standard amounts of a drug given per age; rather, dosage is based on weight using an established amount of the drug per body weight. Body mass index is not considered when determining pediatric medication dosing.
A nurse is preparing to take the temperature of a newborn. Which type of temperature measurement should she use in this situation?
R:In newborns, take the temperature using the axilla. Never take it rectally because of the danger of damaging the rectal mucosa with a thermometer. Moreover, tympanic membrane temperatures may not be effective in newborns because vernix is still present in their ears. Oral measurement of temperature would not be safe in a newborn.
The nurse is caring for a 15-year-old boy with chronic lung disease. Choose the appropriate interventions for this boy. Select all that apply.
Assist the teen in developing effective interpersonal skills.
• Urge the adolescent to make up missed schoolwork.
• Promote participation in after-school activities.
• Educate school staff about the teenager's special needs.
R:Teenagers with special healthcare needs often need to work on interpersonal skills appropriate for their developmental age. Illness, treatments, missed school days, and differences in abilities from their peers interfere with opportunities to practice relational skills with age-mates and others. Educating the school staff, promoting involvement in after-school activities, and keeping up with schoolwork assist in normalizing the teenager's development. Delay in considering the teen's future and having the parents continue close supervision do not help the adolescent move toward independence and are not suitable interventions.
When assisting a child while she is having a tonic-clonic seizure, it would be important to
protect the child from hitting her arms against furniture.
Age affects how the medication is distributed throughout the body. Which factors affect how medication distribution is altered in infants and young children? Select all that apply.
Infants and young children have an increased percentage of water in their bodies.
• The livers of infants and young children are immature.
R:It is true that infants and young children have an increased percentage of water in their bodies. Infants and young children have immature livers.
The parent of a child with cerebral palsy asks how therapeutic horseback riding might benefit his adolescent. The nurse's response includes: Select all that apply.
• Flexibility, balance, and muscle strength tend to improve.
• Self-esteem and confidence usually get a boost.
R:Flexibility, muscle strength, and balance are fostered due to the horse movement as the teen rides. Improvement in these areas would be particularly helpful to the adolescent with cerebral palsy. Improved self-esteem and confidence are also developmentally important as the youth works to establish identity. Improved appetite and resolution of sleep problems are not attributed to therapeutic horseback riding.
The nurse is caring for a 10-year-old child admitted for a surgical procedure to be done the next day. The nurse takes the child to a special area in the playroom and lets the child "start" an IV on a stuffed bear. Which of the following is this action an example of?
R: Therapeutic play is a play technique used to help the child have a better understanding of what will be happening to him or her in a specific situation.
he nurse at a hospice care facility is caring for a 12-year-old girl. Which intervention best meets the needs of this child?
Urging her to invite her friends to visit
R:Young adolescents require time with their peers. Encouraging her to have visitors would best meet this need. Assuring her illness is not her fault and acting as her personal confidant are interventions suited to school-age children. Explaining her condition in detail meets the needs of an older adolescent.
Any individual taking phenobarbital for a seizure disorder should be taught
never to discontinue the drug abruptly.
R:Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.
Which family member involved in care of the child with special needs do nurses recognize as requiring the greatest amount and widest variety of support?
R:Mothers usually carry the greatest responsibility for care of the child and for family functioning. They require the greatest amount and widest variety of support. However, sleep, meals, vacations, work, free time, self-care, and more are disrupted for everyone in the family. Grandparents often provide much assistance, which creates similar tensions in their lives.
A young hospitalized patient is crying because his mother is going to work to take care of some important business but has promised to return in a few hours. What could the mother do to allay the child's fear that she will not return?
Give him her scarf to keep for her.
R:A caregiver needs to take a break at times and to reassure the child that she will return. The mother can give a personal possession to the child to reassure him that she will return.
The nursing supervisor realizes that one of the staff nurses needs direction in working with parents of children with special needs when which comment is overheard?
"That father just doesn't appreciate how much nurses know about working with special needs kids."
R:The comment about a father's appreciation of nursing knowledge needs investigation by the supervisor. Parents should be engaged as equal partners in the care of their children with special needs. They are experts and understand the full range of their child's care and have found effective ways to provide it. The other comments are appropriate to the situation and involve giving information, checking understanding, and encouraging a parent-to-parent connection.
A child returns to the clinic after an episode of otitis externa, which has resolved. Which of the following would the nurse emphasize as the priority for preventing future episodes?
Keeping ear canals dry
When considering the developmental pharmacokinetics of children, which of the following accurately describes the factors that affect medication distribution in children?
Children have a higher proportion of total body water, a lower proportion of body fat, and an immature blood-brain barrie
The nurse caring for a 6-year-old patient enters the room to administer an oral medication in the form of a pill. The dad at the bedside looks at the pill and tells the nurse that his daughter has a hard time swallowing pills. Which of the following is the best response by the nurse?
Call the pharmacy and ask if the pill can be crushed
The nurse caring for a patient with a cranial injury knows that broad-spectrum antibiotics are used to reduce cerebral edema.
R:Antibiotics or antivirals are used to treat infectious disease processes. Glucocorticoids and diuretics are used to reduce cerebral edema
The nurse is preparing to administer a medication via a syringe pump as ordered for a 2-month-old girl. Which is the priority nursing action?
Verify the medication order
A 5-year-old child asks the nurse what happens at the hospital in which the nurse works. Which of the following statements would be the most appropriate response for the nurse to give this child?
"Some people come here to have babies, or when they're sick or hurt, so we can try to help them get better."
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