Chapter 22: Health Care Adaptations for the Child and Family My Nursing Test Banks

Chapter 22: Health Care Adaptations for the Child and Family

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. The best site for the nurse to use when assessing the pulse rate on a 12-month-old infant is:

a.

Brachial pulse

b.

Apical pulse

c.

Radial pulse

d.

Femoral pulse

ANS: B

Apical pulses are advised for children under age 5 years.

DIF: Cognitive Level: Application REF: 486 OBJ: 11

TOP: Physical Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. When the nurse starts to administer a medication to a 2-month-old child, the nurse discovers there is no ID bracelet on the child. The nurse should:

a.

Give the medication after confirming the childs name from the foot of the crib.

b.

Ask the charge nurse to give the medicine.

c.

Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.

d.

Delay the medication until the admissions office can supply a new ID bracelet.

ANS: C

After confirmation of the childs identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

DIF: Cognitive Level: Analysis REF: 481 OBJ: 2

TOP: ID Bracelets KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen. The nurse determined the adolescent understood the instructions when she stated:

a.

I should wash my perineum with soap and water, then begin to urinate.

b.

I clean the perineum from front to back with an antiseptic wipe before I urinate.

c.

Ill collect the first stream of urine in a sterile container.

d.

I will discard the first void and collect a freshly voided specimen 30 minutes later.

ANS: B

To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

DIF: Cognitive Level: Analysis REF: 493 OBJ: N/A

TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

4. The strategy the nurse might use when administering oral medications to a young child who is reluctant to take it is:

a.

Mix the medication with chocolate milk.

b.

Tell the child that the medication is candy.

c.

Give the medication quickly if the child is crying.

d.

Offer the child fruit juice after the medication is swallowed.

ANS: D

The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with important nutrients such as milk since the child may develop a distaste for the food.

DIF: Cognitive Level: Application REF: 498 OBJ: 5

TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. A parent tells the nurse, Im not sure how to give this medicine to my infant. The nurse would teach the parent to best administer an oral suspension by:

a.

Pouring the medication into a small cup and allowing the infant to drink it

b.

Placing the medication in a nipple and having the infant suck the nipple

c.

Using an oral syringe and placing the medication in the side of the infants mouth

d.

Administering the medication with a dropper onto the back of the infants tongue

ANS: C

An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is placed midway back at the side of the mouth.

DIF: Cognitive Level: Application REF: 500 OBJ: 5

TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. Garamycin ear drops are prescribed for a 4-year-old child. To administer the ear drops the nurse would pull the auricle:

a.

Up and back

b.

Down and back

c.

Up and out

d.

Down and out

ANS: A

For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

DIF: Cognitive Level: Application REF: 501 OBJ: 13

TOP: Administering Ear Drops KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. The nurse explains that the tympanic thermometer is more accurate because:

a.

The thermometer probe is blunt and wide.

b.

It takes a brief time to register.

c.

The tympanic membrane shares circulation with the hypothalamus.

d.

The tympanic membrane and the brain have the same temperature.

ANS: C

The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the hypothalamus share the same circulation.

DIF: Cognitive Level: Application REF: 489 OBJ: 8

TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The intervention that would be correct when a nurse is administering a gastrostomy feeding by gravity is:

a.

Discard the residual and increase the volume of feeding by the amount of residual.

b.

Flush the gastrostomy tube with 2 to 4 oz of water before the feeding.

c.

Refill the syringe with formula after it has completely emptied.

d.

Position the child on the right side after a feeding.

ANS: D

To prevent regurgitation and aspiration, the child is placed in the Fowlers position or on its right side to promote gastric emptying after a gastrostomy tube feeding.

DIF: Cognitive Level: Application REF: 511 OBJ: N/A

TOP: Enteral Feedings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

9. The restraint that is most appropriate for the insertion of an intravenous line in a scalp vein of an infant is the:

a.

Mummy

b.

Clove hitch

c.

Jacket

d.

Elbow

ANS: A

A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.

DIF: Cognitive Level: Comprehension REF: 483 OBJ: 2

TOP: Restraining the Infant KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

10. A child who has a continuous intravenous infusion should be assessed every:

a.

Hour

b.

Two hours

c.

Three hours

d.

Four hours

ANS: A

The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

DIF: Cognitive Level: Knowledge REF: 503 OBJ: 6

TOP: Administering Parenteral Medications

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Risk Reduction

11. The prescription for a 4-month-old is: penicillin G 150,000 units IM bid. The drug is supplied as a unit dose of 600,000 units in a 5-ml vial. The nurse should give the dose as:

a.

1 ml

b.

1.4 ml

c.

1.6 ml

d.

1.8 ml

ANS: B

This dose would have to be given in divided doses as only 1 ml should be injected in one site on an infant.

DIF: Cognitive Level: Application REF: 498 OBJ: 6

TOP: Administering Injections KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. When suctioning a tracheostomy, the nurse will:

a.

Suction for a period of 2 to 3 breaths.

b.

Clear the catheter with water after suctioning for reuse.

c.

Apply suction for no more than 15 seconds.

d.

Establish a regular schedule for suctioning.

ANS: C

Suctioning should be limited to 15 seconds.

DIF: Cognitive Level: Knowledge REF: 510 OBJ: 7

TOP: Respiration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

13. The emergency action for airway obstruction in the infant is to give:

a.

6 to 10 midsternal thrusts

b.

5 back blows followed by 5 chest thrusts

c.

5 chest thrusts followed by 5 back blows

d.

Abdominal thrusts until the object is expelled

ANS: B

Five back blows followed by 5 chest thrusts is the appropriate intervention for airway obstruction in the infant.

DIF: Cognitive Level: Knowledge REF: 514 OBJ: N/A

TOP: Management of Airway Obstruction

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

14. When the 4-year-old asks tearfully if the IM injection will hurt, the nurses most effective response is:

a.

No. It is over before you know it

b.

Yes. It will sting a little.

c.

No. Would you like to see the syringe?

d.

Yes. Your mom and I are going to hold you to help you be still.

ANS: B

Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

DIF: Cognitive Level: Implementation REF: 503 OBJ: 6

TOP: Preparation for an IM Injection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

15. The nurse selects the best site for giving an intramuscular injection to a 15-month-old child, which is the:

a.

Ventrogluteal muscle

b.

Dorsogluteal muscle

c.

Deltoid muscle

d.

Vastus lateralis muscle

ANS: D

The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

DIF: Cognitive Level: Application REF: 502 OBJ: 14

TOP: Administering Injections KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

16. The nurse explains that the factor that affects the infants physiological response to medications is:

a.

Faster metabolism in the liver

b.

Slower intestinal transit

c.

Immature kidney function

d.

Increased secretion of hydrochloric acid

ANS: C

Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of age.

DIF: Cognitive Level: Analysis REF: 495 OBJ: 5

TOP: Physiological Responses to Medication

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. After topical administration of hydrocortisone cream to the buttocks and abdomen of an infant, the nurse should:

a.

Diaper the infant snugly with a disposable diaper.

b.

Cover the area with a transparent dressing.

c.

Apply a cloth diaper.

d.

Place the infant on a plastic pad, undiapered.

ANS: C

Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the child should be left undiapered on a cloth pad.

DIF: Cognitive Level: Analysis REF: 495 OBJ: 5

TOP: Rapid Absorption of Drug KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

18. On entering the hospital room, the nurse takes note of all the options below. The observation that would indicate a need for the parents to receive safety education to prevent unintentional injury is:

a.

The blanket is not tucked into the mattress.

b.

Diapers and wipes are stacked at the foot of the crib.

c.

The crib side is locked in the up position.

d.

Pillows are stacked on the bedside table.

ANS: B

Disposable diapers and supplies must be kept out of the infants reach to prevent accidental suffocation.

DIF: Cognitive Level: Analysis REF: 483 OBJ: 2

TOP: Essential Safety Measures KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

19. The nurse prepares a 9-year-old child for a lumbar puncture by explaining that the position for this procedure is:

a.

On your stomach with your head turned to the side.

b.

On your side, keeping the legs bent and the head arched back.

c.

On your back with your legs extended straight out.

d.

On your side with the knees bent and the head close to the knees.

ANS: D

The child is positioned on its side with the knees flexed, and the head is brought down close to the flexed knees.

DIF: Cognitive Level: Application REF: 494 OBJ: 4

TOP: Collecting Specimens-Lumbar Puncture

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

20. The nurse is caring for a 4-year-old child. When reviewing yesterdays intake and output record, the nurse would expect the childs daily urinary output to be approximately:

a.

400 to 500 ml

b.

500 to 600 ml

c.

600 to 700 ml

d.

700 to 1000 ml

ANS: C

The average daily excretion of urine for a 4-year-old child is 600 to 700 ml.

DIF: Cognitive Level: Knowledge REF: 506 OBJ: 12

TOP: Collecting Specimens-Urine Output

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. The nurse would record the infants urine output as:

a.

47 ml

b.

44.5 ml

c.

43.5 ml

d.

40.5 ml

ANS: B

Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. Key Point: One gram is equivalent to one milliliter of output.

47 2.5 = 44.5 grams = 44.5 ml of urine.

DIF: Cognitive Level: Application REF: 507 OBJ: 12

TOP: Collecting Specimens-Urine Output

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

1. The nurse clarifies that the informed consent for a minor guarantees that the parent or legal guardian understands:

Select all that apply.

a.

Purpose of the procedure

b.

Associated risks

c.

No suit can be brought for damages

d.

The document must be signed and witnessed

e.

Information given

ANS: A, B, D, E

The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed.

DIF: Cognitive Level: Comprehension REF: 481 OBJ: 2

TOP: Informed Consent KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

COMPLETION

1. The nurse is searching through several blood pressure cuffs to find a cuff that is the appropriate size for her small patient. The nurse selects a cuff that covers ____________________ of the patients upper arm.

ANS: two thirds

DIF: Cognitive Level: Application REF: 486 OBJ: 8

TOP: Selection of Blood Pressure Cuff KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

NOT: Rationale: No matter the age of the client, in order for the blood pressure cuff to provide an accurate reading it should cover two thirds of the upper arm. A smaller cuff will give an inaccurately high reading and a larger cuff will give an inaccurately low reading.

2. The nurse is aware that for the 3-month-old who has a surgery time of 2:30 PM, the start order for NPO should be no earlier than ____________________.

ANS: 8:30 AM

DIF: Cognitive Level: Application REF: 515 OBJ: 8

TOP: NPO Orders in Infants KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

NOT: Rationale: Periods of NPO should not exceed 4 to 6 hours for pediatric clients because they can become dehydrated very quickly.

3. The order reads: Give Ampicillin oral suspension 400 mg PO every day. The vial reads Ampicillin 125 mg/5 ml. The nurse will give a dose of ____________________ ml.

ANS: 16

DIF: Cognitive Level: Application REF: 498 OBJ: 15

TOP: Pediatric Dose Calculation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. The physician has ordered phenytoin syrup 20 mg PO q.i.d. for a child that weighs 15 pounds. The PDR states that 10 mg/kg/day is the maximum daily dose. The safe dose of this medication is ____________________ mg.

ANS: 68

DIF: Cognitive Level: Application REF: 498 OBJ: 15

TOP: Dose Calculation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

NOT: Rationale: 15 pounds = 6.8 kilograms; 6.8 10 mg = 68 mg maximum dose

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