Chapter 13 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 13

Question 1

Type: MCSA

The parents of a 2-year-old child who sustained severe head trauma from falling out a second-story window are arguing in the pediatric intensive-care unit (PICU) and are blaming each other for the childs accident. The best nursing diagnosis for this family is

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:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 03. Identify the coping mechanisms used by the child and family in response to stress.

Question 2

Type: MCMA

The emergency-room nurse receives a 3-year-old child who was hit by a car. The nurses priority interventions are to which of the following?

Standard Text: Select all that apply.

1. Perform a rapid head-to-toe assessment.

2. Record the parents insurance information.

3. Assess airway, breathing, and circulation.

4. Ask the parents about organ donation.

5. Ask 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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 3

Type: MCMA

A 6-year-old child is in the pediatric intensive-care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway and collided with a car. The nurse may expect which of the following nursing diagnoses with parents of this child?

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:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 02. Describe 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, the priority nursing statement would be which one of the following?

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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe 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. The most appropriate nursing diagnosis is

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:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 04. Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 6

Type: MCSA

A 16-year-old boy has a stiff neck, a headache, a fever of 103 degrees Fahrenheit, and purpuric lesions on his legs. Although the adolescents physical needs take priority at the present time, the nurse can expect which of the following to be the most significant psychological stressor for this adolescent?

1. 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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. 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. The most effective nursing intervention to achieve this goal is which one of the following?

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. Health-care providers, no matter how competent or caring, cannot substitute for parents. Children often cannot 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. Health-care providers, no matter how competent or caring, cannot substitute for parents. Children often cannot 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. Health-care providers, no matter how competent or caring, cannot substitute for parents. Children often cannot 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. Health-care providers, no matter how competent or caring, cannot substitute for parents. Children often cannot recognize nor care about state-of-the-art equipment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 01. Summarize the childs experiences of a life-threatening illness or injury according to developmental level.

Question 8

Type: MCSA

A 12-year-old child with congenital heart block codes in the emergency room. The parents witness this and stare at the resuscitation scene unfolding before them. The best nursing intervention in this situation is

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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. 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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Develop a nursing care plan to provide family-centered care for the dying child and family.

Question 10

Type: MCSA

A 10-year-old is admitted to the PICU in critical condition after a motor vehicle accident. What 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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 04. 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 intensive care unit have been experiencing the shock and disbelief of the situation. What statement by the parents would tell the nurse 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:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 07. Implement strategies for bereavement support of 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. What 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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 13

Type: MCSA

Which child in the intensive care unit 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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 14

Type: MCSA

Siblings of a child in intensive care are preparing to visit their brother, who was hit by a car while riding his bike. What 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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 02. Describe the familys experience and reactions to having a child with a life-threatening illness or injury.

Question 15

Type: MCSA

A 2-year-old is in end-stage renal failure. What 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 2-year-old 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 2-year-old 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 than for a 2-year-old.

Rationale 2: A 2-year-old 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 2-year-old 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 than for a 2-year-old.

Rationale 3: A 2-year-old 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 2-year-old 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 than for a 2-year-old.

Rationale 4: A 2-year-old 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 2-year-old 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 than for a 2-year-old.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Develop a nursing care plan to provide family-centered care for the dying child and family.

Question 16

Type: MCMA

What 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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Develop a nursing care plan for the child with a life-threatening illness or injury.

Question 17

Type: MCSA

Supportive care for the family of an infant who died from Sudden Infant Death Syndrome (SIDS) includes

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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Implement strategies for bereavement support of the parents and siblings after the death of a child.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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