Chapter 13 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 13

Question 1

Type: MCSA

The parents of a toddler-age child who sustained severe head trauma from falling out a second-story window are arguing in the pediatric intensive-care unit (PICU) and blaming each other for the childs accident. Which nursing diagnosis is most appropriate for this family?

1. Parental Role Conflict Related to Protecting the Child

2. Hopelessness Related to the Childs Deteriorating Condition

3. Anxiety Related to the Critical-Care-Unit Environment

4. Family Coping: Compromised, Related to the Childs Critical Injury

Correct Answer: 4

Rationale 1: The parents are displaying ineffective coping behaviors as a family. Parental role conflict does not refer to the parents argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. Each parent may be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

Rationale 2: The parents are displaying ineffective coping behaviors as a family. Parental role conflict does not refer to the parents argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. Each parent may be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

Rationale 3: The parents are displaying ineffective coping behaviors as a family. Parental role conflict does not refer to the parents argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. Each parent may be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

Rationale 4: The parents are displaying ineffective coping behaviors as a family. Parental role conflict does not refer to the parents argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. Each parent may be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

Global Rationale: The parents are displaying ineffective coping behaviors as a family. Parental role conflict does not refer to the parents argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. Each parent may be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 13.3 Identify the coping mechanisms used by the child and family in response to stress.

Question 2

Type: MCMA

The emergency-room nurse receives a preschool-age child who was hit by a car. Which nursing interventions are a priority for this child?

Standard Text: Select all that apply.

1. Performing a rapid head-to-toe assessment

2. Recording the parents insurance information

3. Assessing airway, breathing, and circulation

4. Asking the parents about organ donation

5. Asking the parents if anyone witnessed the accident

Correct Answer: 1,3

Rationale 1: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the childs injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the childs point of impact with the car and mechanism of injury, but this is not the initial priority.

Rationale 2: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the childs injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the childs point of impact with the car and mechanism of injury, but this is not the initial priority.

Rationale 3: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the childs injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the childs point of impact with the car and mechanism of injury, but this is not the initial priority.

Rationale 4: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the childs injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the childs point of impact with the car and mechanism of injury, but this is not the initial priority.

Rationale 5: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the childs injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the childs point of impact with the car and mechanism of injury, but this is not the initial priority.

Global Rationale: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the childs injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the childs point of impact with the car and mechanism of injury, but this is not the initial priority.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 3

Type: MCMA

A young school-age child is in the pediatric intensive-care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway and collided with a car. Which nursing diagnoses may be appropriate for this family?

Standard Text: Select all that apply.

1. Guilt Related to Lack of Child Supervision and Safety Precautions

2. Family Coping: Compromised, Related to the Critical Injury of the Child

3. Parental Role Conflict Related to Childs Injuries and PICU Policies

4. Knowledge Deficit Related to Home Care of Fractured Femur

5. Anger Related to Feelings of Helplessness

Correct Answer: 1,2,3,5

Rationale 1: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

Rationale 2: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

Rationale 3: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

Rationale 4: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

Rationale 5: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

Global Rationale: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 13.2 Examine the familys experience and reactions to having a child with a life-threatening illness or injury.

Question 4

Type: MCSA

The nurse must prepare parents to see their adolescent daughter in the pediatric intensive-care unit (PICU). The child arrived by life flight after experiencing multiple traumas in a car accident involving a suspected drunk driver. At this time, which statement by the nurse to the family is the most appropriate?

1. Dont worry; everything will be okay. We will take excellent care of your child.

2. You should press charges against the drunk driver.

3. Your childs leg was crushed and may have to be amputated.

4. Your childs condition is very critical; her face is swollen, and she may not look like herself.

Correct Answer: 4

Rationale 1: The priority is to prepare the parents for the childs changed appearance. The nurse must not offer false reassurance nor project future stressful events. Truthful statements about the childs condition can be introduced after the parents have seen the child and grasped the situation. The nurse supports the family but remains nonjudgmental about accident details.

Rationale 2: The priority is to prepare the parents for the childs changed appearance. The nurse must not offer false reassurance nor project future stressful events. Truthful statements about the childs condition can be introduced after the parents have seen the child and grasped the situation. The nurse supports the family but remains nonjudgmental about accident details.

Rationale 3: The priority is to prepare the parents for the childs changed appearance. The nurse must not offer false reassurance nor project future stressful events. Truthful statements about the childs condition can be introduced after the parents have seen the child and grasped the situation. The nurse supports the family but remains nonjudgmental about accident details.

Rationale 4: The priority is to prepare the parents for the childs changed appearance. The nurse must not offer false reassurance nor project future stressful events. Truthful statements about the childs condition can be introduced after the parents have seen the child and grasped the situation. The nurse supports the family but remains nonjudgmental about accident details.

Global Rationale: The priority is to prepare the parents for the childs changed appearance. The nurse must not offer false reassurance nor project future stressful events. Truthful statements about the childs condition can be introduced after the parents have seen the child and grasped the situation. The nurse supports the family but remains nonjudgmental about accident details.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.2 Examine the familys experience and reactions to having a child with a life-threatening illness or injury.

Question 5

Type: MCSA

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

1. Potential for Imbalanced Nutrition, More Than Body Requirements Related to Inactivity

2. Anxiety Related to Leaving Chores Undone at Home

3. Potential for Fear of Future Pain Related to Medical Procedures

4. Powerlessness (Moderate) Related to Inability to Speak to or Communicate with Friends

Correct Answer: 4

Rationale 1: The adolescent values communication with peers and may feel frustrated that he cannot speak to them while intubated. The adolescent is present-oriented and is unlikely to worry about household chores or future unknown procedures. The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Rationale 2: The adolescent values communication with peers and may feel frustrated that he cannot speak to them while intubated. The adolescent is present-oriented and is unlikely to worry about household chores or future unknown procedures. The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Rationale 3: The adolescent values communication with peers and may feel frustrated that he cannot speak to them while intubated. The adolescent is present-oriented and is unlikely to worry about household chores or future unknown procedures. The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Rationale 4: The adolescent values communication with peers and may feel frustrated that he cannot speak to them while intubated. The adolescent is present-oriented and is unlikely to worry about household chores or future unknown procedures. The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Global Rationale: The adolescent values communication with peers and may feel frustrated that he cannot speak to them while intubated. The adolescent is present-oriented and is unlikely to worry about household chores or future unknown procedures. The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 13.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 6

Type: MCSA

An adolescent client has a stiff neck, a headache, a fever of 103 degrees Fahrenheit, and purpuric lesions noted on the legs. Although the adolescents physical needs take priority at the present time, the nurse can expect which to be the most significant psychological stressor forthis adolescent?

1. Separation from parents and home.

2. Separation from friends and permanent changes in appearance

3. Fear of painful procedures and bodily mutilation

4. Fear of getting behind in schoolwork

Correct Answer: 2

Rationale 1: Adolescents are developing their identity and rely most on their friends. They are concerned about their appearance and how they look compared to their peers. Separation from parents and home is the main psychological stressor for infants and toddlers. Preschoolers fear pain and bodily mutilation. School-age children are developing a sense of industry and fear getting behind in schoolwork.

Rationale 2: Adolescents are developing their identity and rely most on their friends. They are concerned about their appearance and how they look compared to their peers. Separation from parents and home is the main psychological stressor for infants and toddlers. Preschoolers fear pain and bodily mutilation. School-age children are developing a sense of industry and fear getting behind in schoolwork.

Rationale 3: Adolescents are developing their identity and rely most on their friends. They are concerned about their appearance and how they look compared to their peers. Separation from parents and home is the main psychological stressor for infants and toddlers. Preschoolers fear pain and bodily mutilation. School-age children are developing a sense of industry and fear getting behind in schoolwork.

Rationale 4: Adolescents are developing their identity and rely most on their friends. They are concerned about their appearance and how they look compared to their peers. Separation from parents and home is the main psychological stressor for infants and toddlers. Preschoolers fear pain and bodily mutilation. School-age children are developing a sense of industry and fear getting behind in schoolwork.

Global Rationale: Adolescents are developing their identity and rely most on their friends. They are concerned about their appearance and how they look compared to their peers. Separation from parents and home is the main psychological stressor for infants and toddlers. Preschoolers fear pain and bodily mutilation. School-age children are developing a sense of industry and fear getting behind in schoolwork.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 13.3 Identify the coping mechanisms used by the child and family in response to stress.

Question 7

Type: MCSA

A school bus carrying children in grades K12 crashed into a ravine. The critically injured children were transported by ambulance and admitted to the pediatric intensive-care unit (PICU). The nurse is concerned about calming the frightened children. Which nursing intervention is most appropriate to achieve the goal of calming the frightened children?

1. Tell the children that the physicians are competent.

2. Assure the children that the nurses are caring.

3. Explain that the PICU equipment is state of the art.

4. Call the childrens parents to come into the PICU.

Correct Answer: 4

Rationale 1: A sense of physical and psychological security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Children often neither recognize nor care about state-of-the-art equipment.

Rationale 2: A sense of physical and psychological security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Children often neither recognize nor care about state-of-the-art equipment.

Rationale 3: A sense of physical and psychological security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Children often neither recognize nor care about state-of-the-art equipment

Rationale 4: A sense of physical and psychological security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Children often neither recognize nor care about state-of-the-art equipment.

Global Rationale: A sense of physical and psychological security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Children often neither recognize nor care about state-of-the-art equipment.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.1 Summarize the effects of a life-threatening illness or injury on children.

Question 8

Type: MCSA

A school-age child with congenital heart block codes in the emergency department (ED). The parents witness this and stare at the resuscitation scene unfolding before them. Which nursing intervention is most appropriate in this situation?

1. Ask the parents to leave until the child has stabilized.

2. Ask the parents to call the family to come into watch the resuscitation.

3. Ask the parents to sit near the childs face and hold her hand.

4. Ask the parents to stand at the foot of the cart to watch.

Correct Answer: 3

Rationale 1: Parents should be helped to support their child through emergency procedures, if they are able. Parents should never be asked to take part in emergency efforts unless absolutely necessary. Merely watching the resuscitation serves no purpose for the child. If the parents interfere with resuscitation efforts or they are unable to tolerate the situation, they can be asked to leave later.

Rationale 2: Parents should be helped to support their child through emergency procedures, if they are able. Parents should never be asked to take part in emergency efforts unless absolutely necessary. Merely watching the resuscitation serves no purpose for the child. If the parents interfere with resuscitation efforts or they are unable to tolerate the situation, they can be asked to leave later.

Rationale 3: Parents should be helped to support their child through emergency procedures, if they are able. Parents should never be asked to take part in emergency efforts unless absolutely necessary. Merely watching the resuscitation serves no purpose for the child. If the parents interfere with resuscitation efforts or they are unable to tolerate the situation, they can be asked to leave later.

Rationale 4: Parents should be helped to support their child through emergency procedures, if they are able. Parents should never be asked to take part in emergency efforts unless absolutely necessary. Merely watching the resuscitation serves no purpose for the child. If the parents interfere with resuscitation efforts or they are unable to tolerate the situation, they can be asked to leave later.

Global Rationale: Parents should be helped to support their child through emergency procedures, if they are able. Parents should never be asked to take part in emergency efforts unless absolutely necessary. Merely watching the resuscitation serves no purpose for the child. If the parents interfere with resuscitation efforts or they are unable to tolerate the situation, they can be asked to leave later.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

Question 9

Type: MCSA

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

1. One of you might take a leave of absence to be here more.

2. Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU?

3. Perhaps the grandparents can make the visits for you.

4. Why cant you visit after work every day?

Correct Answer: 2

Rationale 1: Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU? is therapeutic; it focuses on feelings and offers support to the parents. The other options do not focus on how the parents feel and attempt to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

Rationale 2: Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU? is therapeutic; it focuses on feelings and offers support to the parents. The other options do not focus on how the parents feel and attempt to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

Rationale 3: Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU? is therapeutic; it focuses on feelings and offers support to the parents. The other options do not focus on how the parents feel and attempt to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

Rationale 4: Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU? is therapeutic; it focuses on feelings and offers support to the parents. The other options do not focus on how the parents feel and attempt to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

Global Rationale: Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU? is therapeutic; it focuses on feelings and offers support to the parents. The other options do not focus on how the parents feel and attempt to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

Question 10

Type: MCSA

A school-age client is admitted to the pediatric intensive care unit (PICU) in critical condition after a motor vehicle accident. Which intervention should be implemented at this time?

1. Maintain consistent caregivers.

2. Turn the lights off at night.

3. Keep alarm levels low.

4. Consult the hospital play therapist.

Correct Answer: 1

Rationale 1: The intensive care environment is fast-paced, overwhelming, and frightening. Maintaining consistent caregivers is invaluable in developing a familiar and trusting relationship with the child. Turning off the lights in an intensive care environment is not feasible. Keeping alarm levels low could increase risk of injury if an alarm is not heard by staff. Consulting the play therapist is not appropriate at this time.

Rationale 2: The intensive care environment is fast-paced, overwhelming, and frightening. Maintaining consistent caregivers is invaluable in developing a familiar and trusting relationship with the child. Turning off the lights in an intensive care environment is not feasible. Keeping alarm levels low could increase risk of injury if an alarm is not heard by staff. Consulting the play therapist is not appropriate at this time.

Rationale 3: The intensive care environment is fast-paced, overwhelming, and frightening. Maintaining consistent caregivers is invaluable in developing a familiar and trusting relationship with the child. Turning off the lights in an intensive care environment is not feasible. Keeping alarm levels low could increase risk of injury if an alarm is not heard by staff. Consulting the play therapist is not appropriate at this time.

Rationale 4: The intensive care environment is fast-paced, overwhelming, and frightening. Maintaining consistent caregivers is invaluable in developing a familiar and trusting relationship with the child. Turning off the lights in an intensive care environment is not feasible. Keeping alarm levels low could increase risk of injury if an alarm is not heard by staff. Consulting the play therapist is not appropriate at this time.

Global Rationale: The intensive care environment is fast-paced, overwhelming, and frightening. Maintaining consistent caregivers is invaluable in developing a familiar and trusting relationship with the child. Turning off the lights in an intensive care environment is not feasible. Keeping alarm levels low could increase risk of injury if an alarm is not heard by staff. Consulting the play therapist is not appropriate at this time.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 13.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 11

Type: MCSA

Parents of a child in the pediatric intensive care unit (PICU) have been experiencing shock and disbelief regarding their situation. Which statement by the parents indicates they are moving forward into the next stage of coping?

1. Why not me instead of my child?

2. It is hard for me to have others take care of my child.

3. I feel like life is suspended in time.

4. I am glad I can help with his care.

Correct Answer: 1

Rationale 1: The parents initially enter the stage of shock and disbelief. Asking Why not me instead of my child? shows they are moving into the next stage, which is anger and disbelief. Having feelings about others caring for their child is the third stage of deprivation and loss. The feeling of being suspended in time is the fourth stage, which is anticipatory guidance.

Rationale 2: The parents initially enter the stage of shock and disbelief. Asking Why not me instead of my child? shows they are moving into the next stage, which is anger and disbelief. Having feelings about others caring for their child is the third stage of deprivation and loss. The feeling of being suspended in time is the fourth stage, which is anticipatory guidance.

Rationale 3: The parents initially enter the stage of shock and disbelief. Asking Why not me instead of my child? shows they are moving into the next stage, which is anger and disbelief. Having feelings about others caring for their child is the third stage of deprivation and loss. The feeling of being suspended in time is the fourth stage, which is anticipatory guidance.

Rationale 4: The parents initially enter the stage of shock and disbelief. Asking Why not me instead of my child? shows they are moving into the next stage, which is anger and disbelief. Having feelings about others caring for their child is the third stage of deprivation and loss. The feeling of being suspended in time is the fourth stage, which is anticipatory guidance.

Global Rationale: The parents initially enter the stage of shock and disbelief. Asking Why not me instead of my child? shows they are moving into the next stage, which is anger and disbelief. Having feelings about others caring for their child is the third stage of deprivation and loss. The feeling of being suspended in time is the fourth stage, which is anticipatory guidance.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 13.7 Plan bereavement support for the parents and siblings after the death of a child.

Question 12

Type: MCSA

A child is on a ventilator in the pediatric intensive care unit (PICU). Which nursing intervention would best meet the psychosocial needs of this child?

1. Allow the parents to remain at the bedside.

2. Touch and talk to the child often.

3. Provide the child with a blanket from home.

4. Provide consistent caregivers.

Correct Answer: 2

Rationale 1: Touch and verbal exchanges will aid in psychosocial support. The other responses provide a sense of security.

Rationale 2: Touch and verbal exchanges will aid in psychosocial support. The other responses provide a sense of security.

Rationale 3: Touch and verbal exchanges will aid in psychosocial support. The other responses provide a sense of security.

Rationale 4: Touch and verbal exchanges will aid in psychosocial support. The other responses provide a sense of security.

Global Rationale: Touch and verbal exchanges will aid in psychosocial support. The other responses provide a sense of security.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 13

Type: MCSA

Which client in the pediatric intensive care unit (PICU) would most benefit from palliative care?

1. A child with end-stage leukemia.

2. A child with a broken arm after a motor vehicle accident.

3. A child with burn injuries to the legs.

4. A child with recurrent asthma.

Correct Answer: 3

Rationale 1: A child with burn injuries to the legs will benefit most from palliative care to help control pain, anxiety, sleep disturbances, etc. The child with end-stage leukemia will benefit from hospice care. The child with a broken arm or recurrent asthma will not need palliative care.

Rationale 2: A child with burn injuries to the legs will benefit most from palliative care to help control pain, anxiety, sleep disturbances, etc. The child with end-stage leukemia will benefit from hospice care. The child with a broken arm or recurrent asthma will not need palliative care.

Rationale 3: A child with burn injuries to the legs will benefit most from palliative care to help control pain, anxiety, sleep disturbances, etc. The child with end-stage leukemia will benefit from hospice care. The child with a broken arm or recurrent asthma will not need palliative care.

Rationale 4: A child with burn injuries to the legs will benefit most from palliative care to help control pain, anxiety, sleep disturbances, etc. The child with end-stage leukemia will benefit from hospice care. The child with a broken arm or recurrent asthma will not need palliative care.

Global Rationale: A child with burn injuries to the legs will benefit most from palliative care to help control pain, anxiety, sleep disturbances, etc. The child with end-stage leukemia will benefit from hospice care. The child with a broken arm or recurrent asthma will not need palliative care.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 14

Type: MCSA

Siblings of a client in pediatric intensive care unit (PICU) are preparing to visit their brother, who was hit by a car while riding his bike. Which intervention by the nurse will assist the siblings in preparing for the visit?

1. Spend time developing a relationship with the siblings.

2. Have the parents go with the siblings when they visit.

3. Encourage the siblings to talk to a social worker before seeing their brother.

4. Explain what the siblings will hear and see when they visit.

Correct Answer: 4

Rationale 1: Explaining what the siblings will hear and see when they visit will best prepare them for the visit with their brother. The other responses are good ways to help alleviate stress but wont help prepare the siblings for the visit.

Rationale 2: Explaining what the siblings will hear and see when they visit will best prepare them for the visit with their brother. The other responses are good ways to help alleviate stress but wont help prepare the siblings for the visit.

Rationale 3: Explaining what the siblings will hear and see when they visit will best prepare them for the visit with their brother. The other responses are good ways to help alleviate stress but wont help prepare the siblings for the visit.

Rationale 4: Explaining what the siblings will hear and see when they visit will best prepare them for the visit with their brother. The other responses are good ways to help alleviate stress but wont help prepare the siblings for the visit.

Global Rationale: Explaining what the siblings will hear and see when they visit will best prepare them for the visit with their brother. The other responses are good ways to help alleviate stress but wont help prepare the siblings for the visit.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 13.2 Examine the familys experience and reactions to having a child with a life-threatening illness or injury.

Question 15

Type: MCSA

A toddler-age client is in end-stage renal failure. Which nursing intervention will assist this child most?

1. Maintain the childs normal routines.

2. Explain body changes that will take place.

3. Encourage friends to visit.

4. Allow the child to talk about the illness.

Correct Answer: 1

Rationale 1: A toddler has no real concept of death, but does sense changes in routine and parent behavior. Maintaining normal routines is the best intervention to assist this child. A toddler will not understand the body changes; this approach would be more appropriate for a school-age child. Encouraging friends to visit and allowing the child to talk about the illness are more appropriate for older children.

Rationale 2: A toddler has no real concept of death, but does sense changes in routine and parent behavior. Maintaining normal routines is the best intervention to assist this child. A toddler will not understand the body changes; this approach would be more appropriate for a school-age child. Encouraging friends to visit and allowing the child to talk about the illness are more appropriate for older children.

Rationale 3: A toddler has no real concept of death, but does sense changes in routine and parent behavior. Maintaining normal routines is the best intervention to assist this child. A toddler will not understand the body changes; this approach would be more appropriate for a school-age child. Encouraging friends to visit and allowing the child to talk about the illness are more appropriate for older children.

Rationale 4: A toddler has no real concept of death, but does sense changes in routine and parent behavior. Maintaining normal routines is the best intervention to assist this child. A toddler will not understand the body changes; this approach would be more appropriate for a school-age child. Encouraging friends to visit and allowing the child to talk about the illness are more appropriate for older children.

Global Rationale: A toddler has no real concept of death, but does sense changes in routine and parent behavior. Maintaining normal routines is the best intervention to assist this child. A toddler will not understand the body changes; this approach would be more appropriate for a school-age child. Encouraging friends to visit and allowing the child to talk about the illness are more appropriate for older children.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

Question 16

Type: MCMA

Which nursing  interventions would be best for the nursing diagnosis of Powerlessness Related to Relinquishing Control to the Healthcare Team?

Standard Text: Select all that apply.

1. Provide a primary nursing care model.

2. Prepare the child in advance for procedures.

3. Provide optimal pain relief.

4. Explain procedures in developmentally appropriate terms.

5. Incorporate home rituals when possible.

Correct Answer: 2,4,5

Rationale 1: Preparation in advanceand in terms that are developmentally appropriateand incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

Rationale 2: Preparation in advanceand in terms that are developmentally appropriateand incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

Rationale 3: Preparation in advanceand in terms that are developmentally appropriateand incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

Rationale 4: Preparation in advanceand in terms that are developmentally appropriateand incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

Rationale 5: Preparation in advanceand in terms that are developmentally appropriateand incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

Global Rationale: Preparation in advanceand in terms that are developmentally appropriateand incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 17

Type: MCSA

Which intervention is considered supportive care for a family whose infant has died from sudden infant death syndrome (SIDS)?

1. Interviewing parents to determine the cause of the SIDS incident

2. Allowing parents to hold, touch, and rock the infant

3. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints

4. Advising parents that an autopsy is not necessary

Correct Answer: 2

Rationale 1: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy.

Rationale 2: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy.

Rationale 3: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy.

Rationale 4: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy.

Global Rationale: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.7 Plan bereavement support for the parents and siblings after the death of a child.

Question 18

Type: MCMA

The nurse is providing care to an adolescent client who is dying. Which assessment findings indicate the client is experiencing a decrease in peripheral circulation?

Standard Text: Select all that apply.

1. Cool skin

2. Mottled appearance

3. CheyneStokes respirations

4. Increased agitation

5. Increased urine output

Correct Answer: 1,2

Rationale 1: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While CheyneStokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

Rationale 2: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While CheyneStokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

Rationale 3: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While CheyneStokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

Rationale 4: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While CheyneStokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

Rationale 5: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While CheyneStokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

Global Rationale: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While CheyneStokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 13.5 Apply assessment skills to identify the physiologic changes that occur in the dying child.

Question 19

Type: MCMA

A novice nurse in the newborn intensive care unit (NICU) has just performed post-mortem care on a premature infant who passed away. The novice nurse asks to be excused near the end of the shift.  Which interventions can be implemented to support this nurse?

Standard Text: Select all that apply.

1. Schedule additional education on bereavement care

2. Ask a seasoned nurse to talk with the novice nurse

3. Tell the nurse it is ok to grieve with the family

4. Recommend that the nurse transfer to another unit

5. Assign the nurse to stable clients only

Correct Answer: 1,2,3

Rationale 1: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family.  Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

Rationale 2: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family.  Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

Rationale 3: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family.  Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

Rationale 4: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family.  Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

Rationale 5: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family.  Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

Global Rationale: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family.  Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 13.8 Evaluate strategies to support nurses who care for children who die.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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