Chapter 19 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 19

Question 1

Type: MCSA

A nurse is assessing infants for visually related developmental milestones. The infant that is showing a delay in meeting an expected milestone is the

1. 4-month-old who has a social smile.

2. 8-month-old who has just begun to inspect her own hand.

3. 12-month-old who stacks blocks.

4. 7-month-old who picks up a raisin by raking.

Correct Answer: 2

Rationale 1: An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months. A 4-month-old with a social smile, a 12-month-old who stacks blocks, and a 7-month-old who picks up a raisin by raking are all showing appropriate visually related milestones.

Rationale 2: An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months. A 4-month-old with a social smile, a 12-month-old who stacks blocks, and a 7-month-old who picks up a raisin by raking are all showing appropriate visually related milestones.

Rationale 3: An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months. A 4-month-old with a social smile, a 12-month-old who stacks blocks, and a 7-month-old who picks up a raisin by raking are all showing appropriate visually related milestones.

Rationale 4: An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months. A 4-month-old with a social smile, a 12-month-old who stacks blocks, and a 7-month-old who picks up a raisin by raking are all showing appropriate visually related milestones.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 01. Identify anatomy, physiology, and pediatric differences in the eye, ear, nose, and throat of children and adolescents.

Question 2

Type: MCSA

A neonate has been diagnosed with a herpes simplex viral infection of the eye. The nurse will prepare to administer

1. Fluoroquinolones eye drops or ointment.

2. Intravenous penicillin.

3. Oral erythromycin.

4. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment.

Correct Answer: 4

Rationale 1: Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine). Fluoroquinolones eye drops are used to treat bacterial eye infections. Intravenous penicillin treats selected bacterial infections. Oral erythromycin is used to treat chlamydial eye infections.

Rationale 2: Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine). Fluoroquinolones eye drops are used to treat bacterial eye infections. Intravenous penicillin treats selected bacterial infections. Oral erythromycin is used to treat chlamydial eye infections.

Rationale 3: Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine). Fluoroquinolones eye drops are used to treat bacterial eye infections. Intravenous penicillin treats selected bacterial infections. Oral erythromycin is used to treat chlamydial eye infections.

Rationale 4: Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine). Fluoroquinolones eye drops are used to treat bacterial eye infections. Intravenous penicillin treats selected bacterial infections. Oral erythromycin is used to treat chlamydial eye infections.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Question 3

Type: MCSA

The nurse suspects that an infant has a visual disorder caused by abnormal musculature. To detect this disorder, the nurse would perform

1. A cover/uncover test.

2. An ophthalmologic exam.

3. A vision-acuity exam.

4. A pupil-reaction-to-light test.

Correct Answer: 1

Rationale 1: The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature. A vision acuity test is used to test for myopia. A pupil-reaction-to-light test evaluates neurological status.

Rationale 2: The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature. A vision acuity test is used to test for myopia. A pupil-reaction-to-light test evaluates neurological status.

Rationale 3: The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature. A vision acuity test is used to test for myopia. A pupil-reaction-to-light test evaluates neurological status.

Rationale 4: The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature. A vision acuity test is used to test for myopia. A pupil-reaction-to-light test evaluates neurological status.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Plan for screening programs and identification of children with vision and hearing abnormalities.

Question 4

Type: MCSA

The nurse is caring for four clients. The client with the highest risk of developing retinopathy of prematurity is the

1. 30-week-gestation infant who was in an Oxy-Hood for 12 hours and weighed 1800 grams.

2. 32-week-gestation infant who needed no oxygen and weighed 1850 grams.

3. 28-week-gestation infant who has been on long-term oxygen and weighed 1400 grams.

4. 28-week-gestation infant who was on short-term oxygen and weighed 1420 grams.

Correct Answer: 3

Rationale 1: The 28-week-gestation infant on oxygen weighing 1400 grams has the highest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less than 1500 g), and oxygen therapy. The other neonates have fewer risk factors.

Rationale 2: The 28-week-gestation infant on oxygen weighing 1400 grams has the highest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less than 1500 g), and oxygen therapy. The other neonates have fewer risk factors.

Rationale 3: The 28-week-gestation infant on oxygen weighing 1400 grams has the highest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less than 1500 g), and oxygen therapy. The other neonates have fewer risk factors.

Rationale 4: The 28-week-gestation infant on oxygen weighing 1400 grams has the highest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less than 1500 g), and oxygen therapy. The other neonates have fewer risk factors.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 02. Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

Question 5

Type: MCSA

A nurse is caring for a visually impaired 20-month-old who has not begun to walk. An appropriate nursing diagnosis for this child would be

1. Delayed growth and development.

2. Impaired physical mobility.

3. Self-care deficit.

4. Impaired home maintenance.

Correct Answer: 1

Rationale 1: A 20-month-old child who is not walking is delayed in growth and development. The childs mobility is not due to a physiological problem, so impaired mobility is not appropriate. Self-care deficit does not apply to this age of child. There is not enough data to determine if home maintenance is impaired.

Rationale 2: A 20-month-old child who is not walking is delayed in growth and development. The childs mobility is not due to a physiological problem, so impaired mobility is not appropriate. Self-care deficit does not apply to this age of child. There is not enough data to determine if home maintenance is impaired.

Rationale 3: A 20-month-old child who is not walking is delayed in growth and development. The childs mobility is not due to a physiological problem, so impaired mobility is not appropriate. Self-care deficit does not apply to this age of child. There is not enough data to determine if home maintenance is impaired.

Rationale 4: A 20-month-old child who is not walking is delayed in growth and development. The childs mobility is not due to a physiological problem, so impaired mobility is not appropriate. Self-care deficit does not apply to this age of child. There is not enough data to determine if home maintenance is impaired.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 01. Identify anatomy, physiology, and pediatric differences in the eye, ear, nose, and throat of children and adolescents.

Question 6

Type: MCSA

A nurse is caring for a visually impaired 10-year-old child. The nursing intervention with the highest priority for this child during the admission process would be

1. Explaining playroom policies.

2. Orienting the child to where furniture is placed in the room.

3. Letting the child touch equipment that will be used during the hospitalization.

4. Taking the child on a tour of the unit.

Correct Answer: 2

Rationale 1: The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. Policies, handling equipment, and tours can be done at a later time.

Rationale 2: The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. Policies, handling equipment, and tours can be done at a later time.

Rationale 3: The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. Policies, handling equipment, and tours can be done at a later time.

Rationale 4: The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. Policies, handling equipment, and tours can be done at a later time.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Question 7

Type: MCSA

An infant has acute otitis media. The nurse will teach the parents to

1. Keep the baby in a flat lying position during sleep.

2. Administer acetaminophen (Tylenol) to relieve discomfort.

3. Administer a decongestant.

4. Place baby to sleep with a pacifier.

Correct Answer: 2

Rationale 1: An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.

Rationale 2: An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.

Rationale 3: An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.

Rationale 4: An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Use the latest recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

Question 8

Type: MCMA

The nurse has taught parents how to care for their child who has had tympanostomy tubes inserted. The nurse will know the parents understand how to care for their childs tympanostomy tubes if they

Standard Text: Select all that apply.

1. Encourage the child to drink generous amounts of fluids.

2. Administer a decongestant for one to two weeks following surgery.

3. Restrict the child to quiet activities after surgery.

4. Limit diet to soft, bland foods.

5. Avoid getting water in ears during bath time.

Correct Answer: 1,3,5

Rationale 1: The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the childs ears at bath time. Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting diet to soft, bland foodsdecongestants are not needed after surgery, and a regular diet should be resumed.

Rationale 2: The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the childs ears at bath time. Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting diet to soft, bland foodsdecongestants are not needed after surgery, and a regular diet should be resumed.

Rationale 3: The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the childs ears at bath time. Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting diet to soft, bland foodsdecongestants are not needed after surgery, and a regular diet should be resumed.

Rationale 4: The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the childs ears at bath time. Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting diet to soft, bland foodsdecongestants are not needed after surgery, and a regular diet should be resumed.

Rationale 5: The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the childs ears at bath time. Incorrect responses include administering a decongestant for one to two weeks following surgery and limiting diet to soft, bland foodsdecongestants are not needed after surgery, and a regular diet should be resumed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 05. Use the latest recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

Question 9

Type: MCSA

The nurse can assist a child who has a mild hearing loss and reads lips to adapt to hospitalization by

1. Speaking directly to the parents for communication.

2. Speaking in a loud voice while facing the child.

3. Using a picture board as the main means of communication.

4. Touching the child lightly before speaking.

Correct Answer: 4

Rationale 1: The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the childs visual attention by lightly touching the child before communicating. Speaking to the parents only does not help the child with the hospitalization. Speaking in a loud voice may not promote hearing in the child, and a picture board, while useful, should not be the primary means of communication for a child who reads lips.

Rationale 2: The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the childs visual attention by lightly touching the child before communicating. Speaking to the parents only does not help the child with the hospitalization. Speaking in a loud voice may not promote hearing in the child, and a picture board, while useful, should not be the primary means of communication for a child who reads lips.

Rationale 3: The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the childs visual attention by lightly touching the child before communicating. Speaking to the parents only does not help the child with the hospitalization. Speaking in a loud voice may not promote hearing in the child, and a picture board, while useful, should not be the primary means of communication for a child who reads lips.

Rationale 4: The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the childs visual attention by lightly touching the child before communicating. Speaking to the parents only does not help the child with the hospitalization. Speaking in a loud voice may not promote hearing in the child, and a picture board, while useful, should not be the primary means of communication for a child who reads lips.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Integrate evidence-based research to create a nursing care plan for children with vision or hearing impairments.

Question 10

Type: MCSA

A school child has epistaxis. The school nurse appropriately intervenes by

1. Tilting the childs head forward, squeezing the nares below the nasal bone, and applying ice to the nose.

2. Tilting the childs head back, squeezing the bridge of the nose, and applying a warm, moist pack to the nose.

3. Lying the child down and applying no pressure, ice, or warm pack.

4. Immediately packing the nares with a cotton ball soaked with Neo-Synephrine.

Correct Answer: 1

Rationale 1: The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10 to 15 minutes, and apply ice to the nose or back of the head. Tilting the childs head back may cause the blood to trickle down the throat. Warmth can cause an increase in bleeding because of vasodilation. Lying the child down without application of pressure to the nares may not stop the bleeding. A cotton ball soaked with Neo-Synephrine would only be used if the bleeding does not stop with pressure and ice.

Rationale 2: The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10 to 15 minutes, and apply ice to the nose or back of the head. Tilting the childs head back may cause the blood to trickle down the throat. Warmth can cause an increase in bleeding because of vasodilation. Lying the child down without application of pressure to the nares may not stop the bleeding. A cotton ball soaked with Neo-Synephrine would only be used if the bleeding does not stop with pressure and ice.

Rationale 3: The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10 to 15 minutes, and apply ice to the nose or back of the head. Tilting the childs head back may cause the blood to trickle down the throat. Warmth can cause an increase in bleeding because of vasodilation. Lying the child down without application of pressure to the nares may not stop the bleeding. A cotton ball soaked with Neo-Synephrine would only be used if the bleeding does not stop with pressure and ice.

Rationale 4: The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10 to 15 minutes, and apply ice to the nose or back of the head. Tilting the childs head back may cause the blood to trickle down the throat. Warmth can cause an increase in bleeding because of vasodilation. Lying the child down without application of pressure to the nares may not stop the bleeding. A cotton ball soaked with Neo-Synephrine would only be used if the bleeding does not stop with pressure and ice.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Question 11

Type: MCSA

A nurse who is planning to teach school-age children about the common cold should include the information that

1. Vaccinations can prevent contraction of a nasopharyngitis virus.

2. Antibiotics will eliminate the nasopharyngitis virus.

3. Proper handwashing can prevent the spread of the infection.

4. Aspirin should be taken for alleviation of fever if the common cold is contracted.

Correct Answer: 3

Rationale 1: Proper handwashing should be taught to school-age children to reduce the spread of the common cold virus. No vaccine can prevent the common cold. Antibiotics are not used to treat viral infections. Aspirin should not be taken for fever because of its association with Reye syndrome.

Rationale 2: Proper handwashing should be taught to school-age children to reduce the spread of the common cold virus. No vaccine can prevent the common cold. Antibiotics are not used to treat viral infections. Aspirin should not be taken for fever because of its association with Reye syndrome.

Rationale 3: Proper handwashing should be taught to school-age children to reduce the spread of the common cold virus. No vaccine can prevent the common cold. Antibiotics are not used to treat viral infections. Aspirin should not be taken for fever because of its association with Reye syndrome.

Rationale 4: Proper handwashing should be taught to school-age children to reduce the spread of the common cold virus. No vaccine can prevent the common cold. Antibiotics are not used to treat viral infections. Aspirin should not be taken for fever because of its association with Reye syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Question 12

Type: MCSA

A child has been diagnosed with group A beta-hemolytic streptococcus (GABHS) infection of the throat. The nurse should teach the parents to

1. Complete the entire course of antibiotics.

2. Keep the child NPO (nothing by mouth).

3. Continue normal activities.

4. Not allow the child to gargle with saltwater.

Correct Answer: 1

Rationale 1: It is important for parents to complete the entire course of antibiotics for GABHS infections. Nothing-by-mouth, or NPO, status is not recommended because the child needs to stay hydrated. The child should rest, and use of warm saltwater gargles is recommended.

Rationale 2: It is important for parents to complete the entire course of antibiotics for GABHS infections. Nothing-by-mouth, or NPO, status is not recommended because the child needs to stay hydrated. The child should rest, and use of warm saltwater gargles is recommended.

Rationale 3: It is important for parents to complete the entire course of antibiotics for GABHS infections. Nothing-by-mouth, or NPO, status is not recommended because the child needs to stay hydrated. The child should rest, and use of warm saltwater gargles is recommended.

Rationale 4: It is important for parents to complete the entire course of antibiotics for GABHS infections. Nothing-by-mouth, or NPO, status is not recommended because the child needs to stay hydrated. The child should rest, and use of warm saltwater gargles is recommended.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Question 13

Type: MCSA

The nurse has completed postoperative discharge teaching to the parents of a child who has had a tonsillectomy. The nurse will know the parents understand the teaching if they state

1. We will call the physician for any indication of ear pain.

2. We will plan on administering acetaminophen (Tylenol) for pain.

3. We will be sure to give our child adequate amounts of citrus juices.

4. We will keep our child on bed rest for 10 days after the surgery.

Correct Answer: 2

Rationale 1: Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation. Ear pain 4 to 8 days after a tonsillectomy may be experienced and does not indicate an ear infection. Children do not need to be confined to bed. They can return to school in 10 days.

Rationale 2: Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation. Ear pain 4 to 8 days after a tonsillectomy may be experienced and does not indicate an ear infection. Children do not need to be confined to bed. They can return to school in 10 days.

Rationale 3: Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation. Ear pain 4 to 8 days after a tonsillectomy may be experienced and does not indicate an ear infection. Children do not need to be confined to bed. They can return to school in 10 days.

Rationale 4: Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation. Ear pain 4 to 8 days after a tonsillectomy may be experienced and does not indicate an ear infection. Children do not need to be confined to bed. They can return to school in 10 days.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Lo 05. Use the latest recommendations when implementing care and teaching for children with abnormalities of the eyes, ears, nose, throat, and mouth.

Question 14

Type: MCSA

The child who had a tonsillectomy earlier today is now awake and tolerating fluids. The child asks for something to eat. The most appropriate choice would be

1. Orange slices.

2. Lemonade.

3. Grapefruit juice.

4. Applesauce.

Correct Answer: 4

Rationale 1: Soft foods such as applesauce can be added as tolerated to a diet following a tonsillectomy. Citric juices or citric fruits should be avoided because they may cause a burning sensation in the throat.

Rationale 2: Soft foods such as applesauce can be added as tolerated to a diet following a tonsillectomy. Citric juices or citric fruits should be avoided because they may cause a burning sensation in the throat.

Rationale 3: Soft foods such as applesauce can be added as tolerated to a diet following a tonsillectomy. Citric juices or citric fruits should be avoided because they may cause a burning sensation in the throat.

Rationale 4: Soft foods such as applesauce can be added as tolerated to a diet following a tonsillectomy. Citric juices or citric fruits should be avoided because they may cause a burning sensation in the throat.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

Question 15

Type: MCSA

During an admission assessment, the nurse notes that the child has impaired oral mucous membranes. Nursing interventions aimed at resolving the problem would be

1. Administering topical analgesics.

2. Promoting an adequate intake of nutrients.

3. Administering antibiotics as ordered.

4. Using lemon and glycerin for oral hygiene.

Correct Answer: 2

Rationale 1: Adequate intake of fluids and nutrients promotes the intactness of the oral mucosal membrane tissue, which is the desired outcome for an impaired oral mucous membrane problem. Lemon and glycerin may dry the oral mucous membrane, which is not desirable. Administration of antibiotics or topical analgesics are medical interventions that might be performed but do not ensure that impaired tissue will be resolved.

Rationale 2: Adequate intake of fluids and nutrients promotes the intactness of the oral mucosal membrane tissue, which is the desired outcome for an impaired oral mucous membrane problem. Lemon and glycerin may dry the oral mucous membrane, which is not desirable. Administration of antibiotics or topical analgesics are medical interventions that might be performed but do not ensure that impaired tissue will be resolved.

Rationale 3: Adequate intake of fluids and nutrients promotes the intactness of the oral mucosal membrane tissue, which is the desired outcome for an impaired oral mucous membrane problem. Lemon and glycerin may dry the oral mucous membrane, which is not desirable. Administration of antibiotics or topical analgesics are medical interventions that might be performed but do not ensure that impaired tissue will be resolved.

Rationale 4: Adequate intake of fluids and nutrients promotes the intactness of the oral mucosal membrane tissue, which is the desired outcome for an impaired oral mucous membrane problem. Lemon and glycerin may dry the oral mucous membrane, which is not desirable. Administration of antibiotics or topical analgesics are medical interventions that might be performed but do not ensure that impaired tissue will be resolved.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Integrate preventive and treatment principles when implementing care for children related to the eyes, ears, nose, and throat.

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

Copyright 2012 by Pearson Education, Inc.

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