Chapter 20 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 20

Question 1

Type: MCSA

A child is showing signs of acute respiratory distress. The child should be positioned

1. Upright.

2. Side-lying.

3. Flat.

4. In semi-Fowlers.

Correct Answer: 1

Rationale 1: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Rationale 2: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Rationale 3: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Rationale 4: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Distinguish between mild, moderate, and severe respiratory distress in a child, and plan the appropriate nursing care for each level of respiratory distress severity.

Question 2

Type: MCSA

A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. The nurse should instruct the technician to

1. Report any neonate using abdominal muscles to breathe.

2. Report any neonate with apnea for 10 seconds.

3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.

4. Report any neonate with a breathing pause that lasts 20 seconds or longer.

Correct Answer: 4

Rationale 1: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. Its normal for neonates to use abdominal muscles for breathing.

Rationale 2: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. Its normal for neonates to use abdominal muscles for breathing.

Rationale 3: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. Its normal for neonates to use abdominal muscles for breathing.

Rationale 4: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. Its normal for neonates to use abdominal muscles for breathing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Contrast the respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 3

Type: MCSA

A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). The nurse should be prepared to

1. Administer nebulized epinephrine and oral or IM dexamethasone.

2. Administer antibiotics and assist with possible intubation.

3. Swab the throat for a throat culture.

4. Obtain a sputum specimen.

Correct Answer: 1

Rationale 1: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Rationale 2: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Rationale 3: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Rationale 4: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 06. Create a nursing care plan for a child with a common acute respiratory condition.

Question 4

Type: MCSA

The nurse is teaching a group of mothers of infants about the benefits of immunization. The nurse will explain that the life-threatening disease epiglottitis can be prevented by immunization against

1. Measles, mumps, and rubella (MMR).

2. Haemophilus influenzae type B (HIB).

3. Hepatitis B.

4. Polio.

Correct Answer: 2

Rationale 1: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 2: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 3: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 4: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 02. Contrast the respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 5

Type: MCSA

A nurse is assessing a neonate. The assessment that might indicate that the neonates respiratory status is worsening is

1. Acrocyanosis.

2. Arterial CO2 of 40.

3. Periorbital edema.

4. Grunting respirations with nasal flaring.

Correct Answer: 4

Rationale 1: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Rationale 2: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Rationale 3: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Rationale 4: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 04. Assess the childs respiratory status and analyze the need for oxygen supplementation.

Question 6

Type: MCSA

An appropriate nursing diagnosis for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV) would be

1. Activity intolerance.

2. Decreased cardiac output.

3. Pain, acute.

4. Tissue perfusion, ineffective (peripheral).

Correct Answer: 1

Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Rationale 2: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Rationale 3: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Rationale 4: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 02. Contrast the respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 7

Type: MCSA

A child is admitted to the hospital with pneumonia. The childs oximetry reading is 88 percent upon admission to the pediatric floor. The priority nursing activity for this child would be to

1. Obtain a blood sample to send to the lab for electrolyte analysis.

2. Begin oxygen per nasal cannula.

3. Medicate for pain.

4. Begin administration of intravenous fluids.

Correct Answer: 2

Rationale 1: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Rationale 2: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Rationale 3: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Rationale 4: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Assess the childs respiratory status and analyze the need for oxygen supplementation.

Question 8

Type: MCSA

The physician has changed the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse should explain that salmeterol (Serevent) is used to treat asthma because the drug

1. Is an anti-inflammatory.

2. Decreases mucous production.

3. Controls allergic rhinitis.

4. Is a bronchodilator.

Correct Answer: 4

Rationale 1: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Rationale 2: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Rationale 3: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Rationale 4: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Plan the nursing care for the child with a chronic respiratory condition.

Question 9

Type: MCSA

Following parental teaching, the nurse is evaluating the parents understanding of environmental control for their childs asthma management. Teaching has been understood by the parents if they state

1. We will replace the carpet in our childs bedroom with tile.

2. Were glad the dog can continue to sleep in our childs room.

3. Well be sure to use the fireplace often to keep the house warm in the winter.

4. Well keep the plants in our childs room dusted.

Correct Answer: 1

Rationale 1: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Rationale 2: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Rationale 3: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Rationale 4: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 07. Plan the nursing care for the child with a chronic respiratory condition.

Question 10

Type: MCSA

A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse what symptoms made the physician suspect cystic fibrosis. The nurse would reply that the clinical manifestation of cystic fibrosis that is seen first is

1. Steatorrheic stools.

2. Constipation.

3. Meconium ileus.

4. Rectal prolapse.

Correct Answer: 3

Rationale 1: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Rationale 2: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Rationale 3: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Rationale 4: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Contrast the respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 11

Type: MCSA

The nurse is teaching the parents of a newly diagnosed cystic fibrosis patient how to administer the pancreatic enzymes. The nurse will advise the parents to administer the enzymes

1. b.i.d. (twice daily).

2. With meals and snacks.

3. Every 6 hours around the clock.

4. q.i.d. (four times daily).

Correct Answer: 2

Rationale 1: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 2: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 3: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 4: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Plan the nursing care for the child with a chronic respiratory condition.

Question 12

Type: FIB

A child with asthma will be receiving an oral dose of prednisone. The order reads prednisone 2 mg/kg per day. The child weighs 50 lbs. The child will receive ____ milligrams daily. (Round the answer.)

Standard Text:

Correct Answer: 45.5

Rationale : 22.7 2 = 45.5

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Plan the nursing care for the child with a chronic respiratory condition.

Question 13

Type: MCSA

Parents of a child admitted with respiratory distress are concerned because the child wont lie down and wants to sit in a chair leaning forward. The nurse tells the parents that:

1. This helps the child feel in control of his situation.

2. The child needs to be encouraged to lie flat in bed.

3. This position helps keep the airway open.

4. This confirms the child has asthma.

Correct Answer: 3

Rationale 1: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Rationale 2: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Rationale 3: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Rationale 4: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Differentiate between the signs and symptoms of a child with an upper airway and a lower airway respiratory condition.

Question 14

Type: MCSA

A child is on rifampin (Rimactane) for treatment of tuberculosis. The nurse should advise the parents that this drug will be taken for:

1. 2 months.

2. 4 months.

3. 6 months.

4. 8 months.

Correct Answer: 3

Rationale 1: Rifampin is taken for a total of 6 months.

Rationale 2: Rifampin is taken for a total of 6 months.

Rationale 3: Rifampin is taken for a total of 6 months.

Rationale 4: Rifampin is taken for a total of 6 months.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Create a nursing care plan for a child with a common acute respiratory condition.

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

Copyright 2012 by Pearson Education, Inc.

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