The Child with Musculoskeletal or Articular Dysfunction
MULTIPLE CHOICE
1. An 8-year-old child is hit by a motor vehicle in the school parking lot. The school nurse notes
that the child is responding to verbal stimulation but is not moving his extremities when
requested. What is the first action the nurse should take?
a. Wait for the childs parents to arrive.
b. Move the child out of the parking lot.
c. Have someone notify the emergency medical services (EMS) system.
d. Help the child stand to return to play.
ANS: C
The child was involved in a motor vehicle collision and at this time is not able to move his
extremities. The child needs immediate attention at a hospital for assessment of the possibility of
a spinal cord injury. Because the child cannot move his extremities, the child should not be
moved until his cervical and vertebral spines are stabilized. The EMS team can appropriately
stabilize the spinal column for transport. Although it is important to notify the parents, the EMS
system should be activated and transport arranged for serious injuries. The only indication to
move the child is to prevent further trauma.
2. The nurse stops to assist an adolescent who has experienced severe trauma when hit by a
motorcycle. The emergency medical system (EMS) has been activated. The first person who
provided assistance applied a tourniquet to the childs leg because of arterial bleeding. What
should the nurse do related to the tourniquet?
a. Loosen the tourniquet.
b. Leave the tourniquet in place.
c. Remove the tourniquet and apply direct pressure if bleeding is still present.
d. Remove the tourniquet every 5 minutes, leaving it off for 30 seconds each time.
ANS: B
A tourniquet is applied only as a last resort, and then it is left in place and not loosened until
definitive treatment is available. After the tourniquet is applied, skin and tissue necrosis occur
below the site. Loosening or removing the tourniquet allows toxins from the tissue necrosis to be
released into the circulation. This can induce systemic, deadly tourniquet shock.
3. What is a physiologic effect of immobilization on children?
a. Metabolic rate increases.
b. Venous return improves because the child is in the supine position.
c. Circulatory stasis can lead to thrombus and embolus formation.
d. Bone calcium increases, releasing excess calcium into the body (hypercalcemia).
ANS: C
The physiologic effects of immobilization, as a result of decreased muscle contraction, include
venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with
immobilization. With the loss of muscle contraction, there is a decreased venous return to the
heart. Calcium leaves the bone during immobilization, leading to bone demineralization and
increasing the calcium ion concentration in the blood.
4. What condition can result from the bone demineralization associated with immobility?
a. Osteoporosis
b. Pooling of blood
c. Urinary retention
d. Susceptibility to infection
ANS: A
Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures,
extraosseous bone formation, and renal calculi. Pooling of blood is a result of the cardiovascular
effects of immobilization. Urinary retention is secondary to the effect of immobilization on the
urinary tract. Susceptibility to infection can result from the effects of immobilization on the
respiratory and renal systems.
5. What measure is important in managing hypercalcemia in a child who is immobilized?
a. Provide adequate hydration.
b. Change position frequently.
c. Encourage a diet high in calcium.
d. Provide a diet high in calories for healing.
ANS: A
Vigorous hydration is indicated to prevent problems with hypercalcemia. Suggested intake for an
adolescent is 3000 to 4000 ml/day of fluids. Diuretics are used to promote the removal of
calcium. Changing position is important for skin and respiratory concerns. Calcium in the diet is
restricted when possible. A high-protein diet served as frequent snacks with favored foods is
recommended. A high-calorie diet without adequate protein will not promote healing.
6. The nurse is caring for an immobilized preschool child. What intervention is helpful during
this period of immobilization?
a. Encourage wearing pajamas.
b. Let the child have few behavioral limitations.
c. Keep the child away from other immobilized children if possible.
d. Take the child for a walk by wagon outside the room.
ANS: D
Transporting the child outside of the room by stretcher, wheelchair, or wagon increases
environmental stimuli and provides social contact. Street clothes are preferred for hospitalized
children. This decreases the sense of illness and disability. The child needs appropriate limits for
both adherence to the medical regimen and developmental concerns. It is not necessary to keep
the child away from other immobilized children.
7. The nurse is teaching parents the proper use of a hipkneeanklefoot orthosis (HKAFO) for their
4-year-old child. The parents demonstrate basic essential knowledge by making what statement?
a. Alcohol will be used twice a day to clean the skin around the brace.
b. Weekly visits to the orthotist are scheduled to check screws for tightness.
c. Initially, a burning sensation is expected and the brace should remain in place.
d. Condition of the skin in contact with the brace should be checked every 4 hours.
ANS: D
This type of brace has several contact points with the childs skin. To minimize the risk of skin
breakdown and facilitate use of the brace, vigilant skin monitoring is necessary. Alcohol should
not be used on the skin. It is drying. Parents are capable of checking and tightening the screws
when necessary. If a burning sensation occurs, the brace should be removed. If several
complaints of burning occur, the orthotist should be contacted.
8. Immobilization causes what effect on metabolism?
a. Hypocalcemia
b. Decreased metabolic rate
c. Positive nitrogen balance
d. Increased levels of stress hormones
ANS: B
Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased
food intake. Immobilization leads to hypercalcemia and a negative nitrogen balance secondary to
muscle atrophy. Decreased production of stress hormones occurs with decreased physical and
emotional coping capacity.
9. What finding is characteristic of fractures in children?
a. Fractures rarely occur at the growth plate site because it absorbs shock well.
b. Rapidity of healing is inversely related to the childs age.
c. Pliable bones of growing children are less porous than those of adults.
d. The periosteum of a childs bone is thinner, is weaker, and has less osteogenic potential compared to that of an adult.
ANS: B
Healing is more rapid in children. The younger the child, the more rapid the healing process.
Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the
weakest point of long bones and a frequent site of injury during trauma. Childrens bones are
more pliable and porous than those of adults. This allows them to bend, buckle, and break. The
greater porosity increases the flexibility of the bone and dissipates and absorbs a significant
amount of the force on impact. The adult periosteum is thinner, is weaker, and has less
osteogenic potential than that of a child.
10. A 14-year-old is admitted to the emergency department with a fracture of the right humerus
epiphyseal plate through the joint surface. What information does the nurse know regarding this
type of fracture?
a. It will create difficulty because the child is left handed.
b. It will heal slowly because this is the weakest part of the bone.
c. This type of fracture requires different management to prevent bone growth complications.
d. This type of fracture necessitates complete immobilization of the shoulder for 4 to 6 weeks.
ANS: C
This type of fracture (Salter type III) can cause problems with growth in the affected limb. Early
and complete assessment is essential to prevent angular deformities and longitudinal growth
problems. The difficulty for the child does not depend on the location at the epiphyseal plate.
Any fracture of the dominant arm presents obstacles for the individual. Healing is usually rapid
in the epiphyseal plate area. Complete immobilization is not necessary. Often these injuries are
surgically repaired with open reduction and internal fixation.
11. Parents bring a 7-year-old child to the clinic for evaluation of an injured wrist after a bicycle
accident. The parents and child are upset, and the child will not allow an examination of the
injured arm. What priority nursing intervention should occur at this time?
a. Send the child to radiology so radiography can be performed.
b. Initiate an intravenous line and administer morphine for the pain.
c. Calmly ask the child to point to where the pain is worst and to wiggle fingers.
d. Have the parents hold the child so that the nurse can examine the arm thoroughly.
ANS: C
Initially, assessment is the priority. Because the child is alert but upset, the nurse should work to
gain the childs trust. Initial data are gained by observing the childs ability to move the fingers
and to point to the pain. Other important observations at this time are pallor and paresthesia. The
child needs to be sent for radiography, but initial assessment data need to be obtained. Sending
the child for radiography will increase the childs anxiety, making the examination difficult. It is
inappropriate to ask parents to restrain their child. These parents are upset about the injury. If
restraint is indicated, the nurse should obtain assistance from other personnel.
12. A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow
immobilized. What information should be included in the home care instructions?
a. No restrictions of activity are indicated.
b. Elevate casted arm when both upright and resting.
c. The shoulder should be kept as immobile as possible to avoid pain.
d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.
ANS: B
The injured extremity should be kept elevated while resting and in a sling when upright. This
will increase venous return. The child should not engage in strenuous activity for the first few
days. Rest with elevation of the extremity is encouraged. Joints above and below the cast on the
affected extremity should be moved. Swelling of the fingers may indicate neurovascular damage
and should be reported immediately. Permanent damage can occur within 6 to 8 hours.
13. The nurse uses the five Ps to assess ischemia in a child with a fracture. What finding is
considered a late and ominous sign?
a. Petaling
b. Posturing
c. Paresthesia
d. Positioning
ANS: C
Paresthesia distal to the injury or cast is an ominous sign that requires immediate notification of
the practitioner. Permanent muscle and tissue damage can occur within 6 hours. The other signs
of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a
method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral
ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an
ominous sign unless pain was increasing or uncontrollable.
14. A child is upset because, when the cast is removed from her leg, the skin surface is caked
with desquamated skin and sebaceous secretions. What technique should the nurse suggest to
remove this material?
a. Soak in a bathtub.
b. Vigorously scrub the leg.
c. Carefully pick material off the leg.
d. Apply powder to absorb the material.
ANS: A
Simply soaking in the bathtub is usually sufficient for removal of the desquamated skin and
sebaceous secretions. Several days may be required to eliminate the accumulation completely.
The parents and child should be advised not to scrub the leg vigorously or forcibly remove this
material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may
provide comfort for the child.
15. A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a
child at home is complex, the nurse should include what instructions for the parents discharge
teaching?
a. Turn every 8 hours.
b. Specially designed car restraints are necessary.
c. Diapers should be avoided to reduce soiling of the cast.
d. Use an abduction bar between the legs to aid in turning.
ANS: B
Standard seat belts and car seats may not be readily adapted for use by children in some casts.
Specially designed car seats and restraints meet safety requirements. The child must have
position changes much more frequently than every 8 hours. During feeding and play activities,
the child should be moved for both physiologic and psychosocial benefit. Diapers and other
strategies are necessary to maintain cleanliness. The abduction bar is never used as an aid for
turning. Putting pressure on the bar may damage the integrity of the cast.
16. What is an appropriate nursing intervention when caring for a child in traction?
a. Removing adhesive traction straps daily to prevent skin breakdown
b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles
c. Providing active range of motion exercises to affected extremity three times a day
d. Keeping child prone to maintain good alignment
ANS: B
Traction places stress on the affected bone, joint, and muscles. The nurse must assess for
tightness, weakness, or contractures developing in the uninvolved joints and muscles. The
adhesive straps should be released or replaced only when absolutely necessary. Active, passive,
or active with resistance exercises should be carried out for the unaffected extremity only.
Movement is expected with children. Each time the child moves, the nurse should check to
ensure that proper alignment is maintained.
17. The nurse is caring for a hospitalized adolescent whose femur was fractured 18 hours ago.
The adolescent suddenly develops chest pain and dyspnea. The nurse should suspect what
complication?
a. Sepsis
b. Osteomyelitis
c. Pulmonary embolism
d. Acute respiratory tract infection
ANS: C
Fat emboli are of greatest concern in individuals with fractures of the long bones. Fat droplets
from the marrow are transferred to the general circulation, where they are transported to the lung
or brain. This type of embolism usually occurs within the second 12 hours after the injury. Sepsis
would manifest with fever and lethargy. Osteomyelitis usually is seen with pain at the site of
infection and fever. A child with an acute respiratory tract infection would have nasal congestion,
not chest pain.
18. What statement is correct regarding sports injuries during adolescence?
a. Conditioning does not help prevent many sports injuries.
b. The increase in strength and vigor during adolescence helps prevent injuries related to fatigue.
c. More injuries occur during organized athletic competition than during recreational sports participation.
d. Adolescents may not possess insight and judgment to recognize when a sports activity is beyond their capabilities.
ANS: D
Injuries occur when the adolescents body is not suited to the sport or when he or she lacks the
insight and judgment to recognize that an activity exceeds his or her physical abilities. More
injuries occur when an adolescents muscles and body systems (respiratory and cardiovascular)
are not conditioned to endure physical stress. Injuries do not occur from fatigue but rather from
overuse. All sports have the potential for injury to the participant, whether the youngster engages
in serious competition or in sports for recreation. More injuries occur during recreational sports
than during organized athletic competition.
19. The middle school nurse is speaking to parents about prevention of injuries as a goal of the
physical education program. How should the goal be achieved?
a. Use of protective equipment at the familys discretion
b. Education of adults to recognize signs that indicate a risk for injury
c. Sports medicine program to help student athletes work through overuse injuries
d. Arrangements for multiple sports to use same athletic fields to accommodate more children
ANS: B
Adults close to sports activities need to be aware of the early warning signs of fatigue,
dehydration, and risk for injury. School policy should require mandatory use of protective
equipment. Proper sports medicine therapy does not support working through overuse injuries.
Too many students involved in different activities create distractions, which contribute to the
child losing focus. This is a contributing factor to injury.
20. A young girl has just injured her ankle at school. In addition to notifying the childs parents,
what is the most appropriate, immediate action by the school nurse?
a. Apply ice.
b. Observe for edema and discoloration.
c. Encourage child to assume a position of comfort.
d. Obtain parental permission for administration of acetaminophen or aspirin.
ANS: A
Soft tissue injuries should be iced immediately. In addition to ice, the extremity should be rested,
be elevated, and have compression applied. The nurse observes for the edema while placing a
cold pack. The applying of ice can reduce the severity of the injury. Maintaining the ankle at a
position elevated above the heart is important. The nurse helps the child be comfortable with this
requirement. The nurse obtains parental permission for administration of acetaminophen or
aspirin after ice and rest are assured.
21. A student athlete was injured during a basketball game. The nurse observes significant
swelling. The player states he thought he heard a pop, that the pain is pretty bad, and that the
ankle feels as if it is coming apart. Based on this description, the nurse suspects what injury?
a. Sprain
b. Fracture
c. Dislocation
d. Stress fracture
ANS: A
Sprains account for approximately 75% of all ankle injuries in children. A sprain results when the
trauma is so severe that a ligament is either stretched or partially or completely torn by the force
created as a joint is twisted or wrenched. Joint laxity is the most valid indicator of the severity of
a sprain. A fracture involves the cross-section of the bone. Dislocations occur when the force of
stress on the ligaments disrupts the normal positioning of the bone ends. Stress fractures result
from repeated muscular contraction and are seen most often in sports involving repetitive weight
bearing such as running, gymnastics, and basketball.
22. An adolescent comes to the school nurse after experiencing shin splints during a track meet.
What reassurance should the nurse offer?
a. Shin splints are expected in runners.
b. Ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain.
c. It is generally best to run around and work the pain out.
d. Moist heat and acetaminophen are indicated for this type of injury.
ANS: B
Shin splints result when the ligaments tear away from the tibial shaft and cause pain. Actions that
have an antiinflammatory effect are indicated for shin splints. Ice, rest, and NSAIDs are the usual
treatment. Shin splints are rarely serious, but they are not expected, and preventive measures are
taken. Rest is important to heal the shin splints. Continuing to place stress on the tibia can lead to
further damage.
23. The nurse at a summer camp recognizes the signs of heatstroke in an adolescent girl. Her
temperature is 40 C (104 F). She is slightly confused but able to drink water. Nursing care while
waiting for transport to the hospital should include what intervention?
a. Administer antipyretics.
b. Administer salt tablets.
c. Apply towels wet with cool water.
d. Sponge with solution of rubbing alcohol and water.
ANS: C
Heatstroke is a failure of normal thermoregulatory mechanisms. The onset is rapid with initial
symptoms of headache, weakness, and disorientation. Immediate care is relocation to a cool
environment, removal of clothing, and applying of cool water (wet towels or immersion).
Antipyretics are not used because they are metabolized by the liver, which is already not
functioning. Salt tablets are not indicated and may be harmful by increasing dehydration.
Rubbing alcohol is not used.
24. What is the recommended drink for athletes during practice and competition?
a. Sports drinks to replace carbohydrates
b. Cold water for gastrointestinal tract rapid absorption
c. Carbonated beverages to help with acidbase balance
d. Enhanced performance carbohydrateelectrolyte drinks
ANS: B
Water is recommended for most athletes, who should drink 4 to 8 oz every 15 to 20 minutes.
Cold water facilitates rapid gastric emptying and intestinal absorption. Most carbohydrate sports
drinks have 6% to 8% carbohydrate, which can cause gastrointestinal upset. Carbonated
beverages are discouraged. There is no evidence that these drinks enhance function.
25. The nurse is teaching the girls varsity sports teams about the female athlete triad. What is
essential information to include?
a. They should take low to moderate calcium to avoid hypercalcemia.
b. They have strong bones because of the athletic training.
c. Pregnancy can occur in the absence of menstruation.
d. A diet high in carbohydrates accommodates increased training.
ANS: C
Sexually active teenagers, regardless of menstrual status, need to consider contraceptive
precautions. Increased calcium (1500 mg) is recommended for amenorrheic athletes. The
decreased estrogen in girls with the female athlete triad, coupled with potentially inadequate diet,
leads to osteoporosis. Diets high in protein and calories are necessary to avoid potentially long-
term consequences of intensive, prolonged exercise programs in pubertal girls.
26. Parents are considering treatment options for their 5-year-old child with Legg-Calv-Perthes
disease. Both surgical and conservative therapies are appropriate. They are able to verbalize the
differences between the therapies when they make what statement?
a. All therapies require extended periods of bed rest.
b. Conservative therapy will be required until puberty.
c. Our child cannot attend school during the treatment phase.
d. Surgical correction requires a 3- to 4-month recovery period.
ANS: D
Surgical correction involves additional risks of anesthesia, infection, and possibly blood
transfusion. The recovery period is only 3 to 4 months rather than the 2 to 4 years of conservative
therapies. The use of nonweight-bearing appliances and surgical intervention does not require
prolonged bed rest. Conservative therapy is indicated for 2 to 4 years. The child is encouraged to
attend school and engage in activities that can be adapted to therapeutic appliances.
27. A 4-year-old child is placed in Buck extension traction for Legg-Calv-Perthes disease. He is
crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an
absence of pulse. What should the nurse do first?
a. Reposition the child and notify the practitioner.
b. Notify the practitioner of the changes noted.
c. Give the child medication to relieve the pain.
d. Chart the observations and check the extremity again in 15 minutes.
ANS: B
The absence of a pulse and change in color of the foot must be reported immediately for
evaluation by the practitioner. This is an emergency condition. Pain medication should be given
after the practitioner is notified. The findings should be documented with ongoing assessment.
28. What term is used to describe an abnormally increased convex angulation in the curvature of
the thoracic spine?
a. Scoliosis
b. Lordosis
c. Kyphosis
d. Ankylosis
ANS: C
Kyphosis is an abnormally increased convex angulation in the curvature of the thoracic spine.
Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation
causing rib asymmetry, and thoracic hypokyphosis. Lordosis is an accentuation of the cervical or
lumbar curvature beyond physiologic limits. Ankylosis is the immobility of a joint.
29. When does idiopathic scoliosis become most noticeable?
a. In the newborn period
b. When the child starts to walk
c. During the preadolescent growth spurt
d. During adolescence
ANS: C
Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. It is seldom
apparent before age 10 years.
30. A preadolescent has been diagnosed with scoliosis. The planned therapy is the use of a
thoracolumbosacral orthotic. The preadolescent asks how long she will have to wear the brace.
What is the appropriate response by the nurse?
a. For as long as you have been told.
b. Most preadolescents use the brace for 6 months.
c. Until your vertebral column has reached skeletal maturity.
d. It will be necessary to wear the brace for the rest of your life.
ANS: C
Bracing can halt or slow the progress of most curvatures. They must be used continuously until
the child reaches skeletal maturity. Telling the child for as long as you have been told does not
answer the childs question and does not promote involvement in care. Six months is unrealistic
because skeletal maturity is not reached until adolescence. When skeletal growth is complete,
bracing is no longer effective.
31. A 17-year-old patient is returning to the surgical unit after Luque instrumentation for
scoliosis repair. In addition to the usual postoperative care, what additional intervention will be
needed?
a. Position changes are made by log rolling.
b. Assistance is needed to use the bathroom.
c. The head of the bed is elevated to minimize spinal headache.
d. Passive range of motion is instituted to prevent neurologic injury.
ANS: A
After scoliosis repair using a Luque procedure, the adolescent is turned by log rolling to prevent
damage to the fusion and instrumentation. The patient is kept flat in bed for the first 12 hours and
is not ambulatory until the second or third postoperative day. A urinary catheter is placed. The
head of the bed is not elevated until the second postoperative day. Range of motion exercises are
begun on the second postoperative day.
32. What is the primary method of treating osteomyelitis?
a. Joint replacement
b. Bracing and casting
c. Intravenous antibiotic therapy
d. Long-term corticosteroid therapy
ANS: C
Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus
aureus infection. The treatment of choice is antibiotics. Joint replacement, bracing and casting,
and long-term corticosteroid therapy are not indicated for infectious processes.
33. What nursing intervention is most appropriate when caring for the child with osteomyelitis?
a. Encourage frequent ambulation.
b. Administer antibiotics with meals.
c. Move and turn the child carefully and gently to minimize pain.
d. Provide active range of motion exercises for the affected extremity.
ANS: C
During the acute phase, any movement of the affected limb causes discomfort to the child.
Careful positioning with the affected limb supported is necessary. Weight bearing is not
permitted until healing is well under way to avoid pathologic fractures. Intravenous antibiotics
are used initially. Food is not necessary with parenteral therapy. Active range of motion would be
painful for the child.
34. What statement is true concerning osteogenesis imperfecta (OI)?
a. It is easily treated.
b. It is an inherited disorder.
c. Braces and exercises are of no therapeutic value.
d. Later onset disease usually runs a more difficult course.
ANS: B
OI is a heterogeneous, autosomal dominant disorder characterized by fractures and bone
deformity. Treatment is primarily supportive. Several investigational therapies are being
evaluated. The primary goal of therapy is rehabilitation. Lightweight braces and splints help
support limbs, prevent fractures, and aid in ambulation. The disease is present at birth. Prognosis
is affected by the type of OI.
35. What is a major goal for the therapeutic management of juvenile idiopathic arthritis (JIA)?
a. Control pain and preserve joint function.
b. Minimize use of joint and achieve cure.
c. Prevent skin breakdown and relieve symptoms.
d. Reduce joint discomfort and regain proper alignment.
ANS: A
The goals of therapy are to control pain, preserve joint range of motion and function, minimize
the effects of inflammation, and promote normal growth and development. There is no cure for
JIA at this time. Skin breakdown is not an issue for most children with JIA. Symptom relief and
reduction in discomfort are important. When the joints are damaged, it is often irreversible.
36. A child with juvenile idiopathic arthritis (JIA) is started on a nonsteroidal antiinflammatory
drug (NSAID). What nursing consideration should be included?
a. Monitor heart rate.
b. Administer NSAIDs between meals.
c. Check for abdominal pain and bloody stools.
d. Expect inflammation to be gone in 3 or 4 days.
ANS: C
NSAIDs are the first-line drugs used in JIA. Potential side effects include gastrointestinal (GI),
renal, and hepatic side effects. The child is at risk for GI bleeding and elevated blood pressure.
The heart rate is not affected by this drug class. NSAIDs should be given with meals to minimize
gastrointestinal problems. The antiinflammatory response usually takes 3 weeks before
effectiveness can be evaluated.
37. What is an important nursing consideration when caring for a child with juvenile idiopathic
arthritis (JIA)?
a. Apply ice packs to relieve acute swelling and pain.
b. Administer acetaminophen to reduce inflammation.
c. Teach the child and family correct administration of medications.
d. Encourage range of motion exercises during periods of inflammation.
ANS: C
The management of JIA is primarily pharmacologic. The family should be instructed regarding
administration of medications and the value of a regular schedule of administration to maintain a
satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs
should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat
is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects.
Range of motion exercises should not be done during periods of inflammation.
38. What needs to be included as essential teaching for adolescents with systemic lupus
erythematosus (SLE)?
a. High calorie diet because of increased metabolic needs
b. Home schooling to decrease the risk of infections
c. Protection from sun and fluorescent lights to minimize rash
d. Intensive exercise regimen to build up muscle strength and endurance
ANS: C
The photosensitive rash is a major concern for individuals with SLE. Adolescents who spend
time outdoors need to use sunscreens with a high SPF, hats, and clothing. Uncovered fluorescent
lights can also cause a photosensitivity reaction. The diet should be sufficient in calories and
nutrients for growth and development. The use of steroids can cause increased hunger, resulting
in weight gain. This can present additional emotional issues for the adolescent. Normal functions
should be maximized. The individual with SLE is encouraged to attend school and participate in
peer activities. A balance of rest and exercise is important; excessive exercise is avoided.
39. The nurse is teaching the parent of a 4-year-old child with a cast on the arm about care at
home. What statement by the parent indicates a correct understanding of the teaching?
a. I should have the affected limb hang in a dependent position.
b. I will use an ice pack to relieve the itching.
c. I should avoid keeping the injured arm elevated.
d. I will expect the fingers to be swollen for the next 3 days.
ANS: B
Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning
discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent
position for more than 30 minutes. The affected arm should be kept elevated as much as possible.
If there is swelling or redness of the fingers, the parent should notify the health care provider.
40. The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the
hip about preventing skin breakdown under the Pavlik harness. What statement by the parent
would indicate a correct understanding of the teaching?
a. I should gently massage the skin under the straps once a day to stimulate circulation.
b. I will apply a lotion for sensitive skin under the straps after my baby has been given a bath to prevent skin irritation.
c. I should remove the harness several times a day to prevent contractures.
d. I will place the diaper over the harness, preferably using a superabsorbent disposable diaper that is relatively thin.
ANS: A
To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a
Pavlik harness, the parent should gently massage the skin under the straps once a day to
stimulate circulation. The parent should not apply lotions or powder because this could irritate
the skin. The parent should not remove the harness, except during a bath, and should place the
diaper under the straps.
DIF: Cognitive Level: Applying REF: p. 1591
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
41. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be
corrected, what should the nurse explain?
a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.
ANS: C
Serial casting is begun shortly after birth, before discharge from the nursery. Successive casts
allow for gradual stretching of skin and tight structures on the medial side of the foot.
Manipulation and casting of the leg are repeated frequently (every week) to accommodate the
rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is
done only if serial casting is not successful. Children do not improve without intervention.
DIF: Cognitive Level: Understanding REF: p. 1597
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
42. An infant is born with one lower limb deficiency. When is the optimum time for the child to
be fitted with a functional prosthetic device?
a. As soon as possible after birth
b. When the infant is developmentally ready to stand up
c. At about ages 12 to 15 months, when most children are walking
d. At about 4 years, when the healthy limb is not growing so rapidly
ANS: B
An infant should be fitted with a functional prosthetic leg when the infant is developmentally
ready to pull to a standing position. When the infant begins limb exploration, a soft prosthesis
can be used. The child should begin using the prosthesis as part of his or her normal
development. This will match the infants motor readiness.
DIF: Cognitive Level: Analyzing REF: p. 1552
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
43. The nurse knows that parents need further teaching with regard to the treatment of congenital
clubfoot when they state what?
a. Well keep the cast dry.
b. Were happy this is the only cast our baby will need.
c. Well watch for any swelling of the foot while the cast is on.
d. Were getting a special car seat to accommodate the cast.
ANS: B
The common approach to clubfoot management and treatment is the Ponseti method. Serial
casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along
with placement of serial long-leg casts allow for gradual repositioning of the foot. The extremity
or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. If
parents state that this is the only cast the infant will need, they need further teaching.
DIF: Cognitive Level: Applying REF: p. 1597
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
44. A child has just returned from surgery for repair of a fractured femur. The child has a long-
leg cast on. The toes on the leg with the cast are edematous, but they have color, sensitivity, and
movement. What action should the nurse take?
a. Call the health care provider to report the edema.
b. Elevate the foot and leg on pillows.
c. Apply a warm moist pack to the foot.
d. Encourage movement of toes.
ANS: B
During the first few hours after a cast is applied, the chief concern is that the extremity may
continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and
producing neurovascular complications (compartment syndrome). One measure to reduce the
likelihood of this problem is to elevate the body part and thereby increase venous return. The
health care provider does not need to be notified because edema is expected and warm moist
packs will not decrease the edema. The child should move the toes, but that will not help reduce
the edema.
DIF: Cognitive Level: Applying REF: p. 1559
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
45. After spinal fusion surgery the nurse should check for signs of what?
a. Seizure activity
b. Increased intracranial pressure
c. Impaired color, sensitivity, and movement to the lower extremities
d. Impaired pupillary response during neurologic checks
ANS: C
In addition to the usual postoperative assessments of wound, circulation, and vital signs, the
neurologic status of the patients extremities requires special attention. Prompt recognition of any
neurologic impairment is imperative because delayed paralysis may develop that requires
surgical intervention.
DIF: Cognitive Level: Applying REF: p. 1589
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
46. What should the nurse plan for an immobilized child in cervical traction to prevent deep vein
thrombosis (DVT)?
a. Elevate the childs legs.
b. Place a foot cradle on the bed.
c. Place a pillow under the childs knees.
d. Assist the child to dorsiflex the feet and rotate the ankles.
ANS: D
For a child who is immobilized, circulatory stasis and DVT development are prevented by
instructing patients to change positions frequently, dorsiflex their feet and rotate the ankles, sit in
a bedside chair periodically, or ambulate several times daily. Elevating the legs or placing a foot
cradle on the bed will not prevent DVTs. A pillow under the knee would impair circulation, not
improve it.
DIF: Cognitive Level: Applying REF: p. 1551
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
47. The nurse is teaching a child with a cast about cast removal. What should the nurse teach the
child about cast removal?
a. The cast cutter will be a quiet machine.
b. You will feel cold as the cast is removed.
c. You will feel a tickly sensation as the cast is removed.
d. The cast cutter cuts through the cast like a circular saw.
ANS: C
Cutting the cast to remove it or to relieve tightness is frequently a frightening experience for
children. They fear the sound of the cast cutter and are terrified that their flesh, as well as the
cast, will be cut. Because it works by vibration, a cast cutter cuts only the hard surface of the
cast. The oscillating blade vibrates back and forth very rapidly and will not cut when placed
lightly on the skin. Children have described it as producing a tickly sensation.
DIF: Cognitive Level: Applying REF: p. 1557
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
48. A 3-year-old child has a femoral shaft fracture. The nurse recognizes that the approximate
healing time for this child is how long?
a. 2 weeks
b. 4 weeks
c. 6 weeks
d. 8 weeks
ANS: B
The approximate healing times for a femoral shaft fracture are as follows: neonatal period, 2 to 3
weeks; early childhood, 4 weeks; later childhood, 6 to 8 weeks; and adolescence, 8 to 12 weeks.
DIF: Cognitive Level: Understanding REF: p. 1570
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
49. The nurse is teaching infant care to parents with an infant who has been diagnosed with
osteogenesis imperfecta (OI). What should the nurse include in the teaching session?
a. Bisphosphonate therapy is not beneficial for OI.
b. Physical therapy should be avoided as it may cause damage to bones.
c. Lift the infant by the buttocks, not the ankles, when changing diapers.
d. The infant should meet expected gross motor development without assistive devices.
ANS: C
Infants and children with this disorder require careful handling to prevent fractures. They must
be supported when they are being turned, positioned, moved, and held. Even changing a diaper
may cause a fracture in severely affected infants. These children should never be held by the
ankles when being diapered but should be gently lifted by the buttocks or supported with pillows.
Bisphosphonate and physical therapy are beneficial for OI. Lightweight braces will be used when
the child starts to ambulate.
DIF: Cognitive Level: Applying REF: p. 1601
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. In teaching a 16-year-old adolescent who was recently diagnosed with systemic lupus
erythematosus (SLE), what statements should the nurse include? (Select all that apply.)
a. You should use a moisturizer with a sun protection factor (SPF) of 30.
b. You should avoid pregnancy because this can cause a flare-up.
c. You should not receive any immunizations in the future.
d. You may need to be on a low-protein, high-carbohydrate diet.
e. You should expect to lose weight while taking steroids.
f. You may need to modify your daily recreational activities.
ANS: A, B, F
Teaching for an adolescent with SLE should foster adaptation and self-advocacy and include
using a moisturizer with an SPF of 30, avoiding pregnancy because it can produce a flare-up, and
modifying recreational activities but continuing with daily exercise as an essential part of the
treatment plan. The adolescent should continue to receive immunizations as scheduled, should
expect to gain weight while on steroid therapy, and would not have a specialized diet.
DIF: Cognitive Level: Analyzing REF: p. 1610
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
2. The nurse is caring for a child immobilized because of Russel traction. What interventions
should the nurse implement to prevent renal calculi? (Select all that apply.)
a. Monitor output.
b. Encourage the patient to drink apple juice.
c. Encourage milk intake.
d. Ensure adequate fluids.
e. Encourage the patient to drink cranberry juice.
ANS: A, D, E
To prevent renal calculi in a child who is immobilized, a nurse should monitor output; ensure
adequate fluids; and encourage cranberry juice, which acidifies urine. Apple juice and milk
alkalize the urine, so they should not be encouraged.
DIF: Cognitive Level: Applying REF: p. 1561
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3. The nurse is assisting with application of a synthetic cast on a child with a fractured humerus.
What are the advantages of a synthetic cast over a plaster of Paris cast? (Select all that apply.)
a. Less bulky
b. Drying time is faster
c. Molds readily to body part
d. Permits regular clothing to be worn
e. Can be cleaned with small amount of soap and water
ANS: A, B, D, E
The advantages of synthetic casts over plaster of Paris casts are that they are less bulky, dry
faster, permit regular clothes to be worn, and can be cleaned. Plaster of Paris casts mold readily
to a body part, but synthetic casts do not mold easily to body parts.
DIF: Cognitive Level: Analyzing REF: p. 1558 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
4. A child has had a short-arm synthetic cast applied. What should the nurse teach to the child
and parents about cast care? (Select all that apply.)
a. Relieve itching with heat.
b. Elevate the arm when resting.
c. Observe the fingers for any evidence of discoloration.
d. Do not allow the child to put anything inside the cast.
e. Examine the skin at the cast edges for any breakdown.
ANS: B, C, D, E
Cast care involves elevating the arm, observing the fingers for evidence of discoloration, not
allowing the child to put anything inside the cast, and examining the skin at the edges of the cast
for any breakdown. Ice, not heat, should be applied to relieve itching.
DIF: Cognitive Level: Applying REF: p. 1559
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
5. The nurse is conducting preoperative teaching to parents and their child about an external
fixation device. What should the nurse include in the teaching session? (Select all that apply.)
a. Pin care
b. Crutch walking
c. Modifications in activity
d. Observing pin sites for infection
e. Full weight bearing will be allowed after 24 hours
ANS: A, B, C, D
The device is attached surgically by securing a series of external full or half rings to the bone
with wires. Children and parents should be instructed in pin care, including observation for
infection and loosening of pins. Partial weight bearing is allowed, and the child needs to learn to
walk with crutches. Alterations in activity include modifications at school and in physical
education. Full weight bearing is not allowed until the distraction is completed and bone
consolidation has occurred.
DIF: Cognitive Level: Applying REF: p. 1562
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
6. The nurse is caring for a 14-year-old child with systemic lupus erythematous (SLE). What
clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Arthralgia
b. Weight gain
c. Polycythemia
d. Abdominal pain
e. Glomerulonephritis
ANS: A, D, E
Clinical manifestations of SLE include arthralgia, abdominal pain, and glomerulonephritis.
Weight loss, not gain, and anemia, not polycythemia, are manifestations of SLE.
DIF: Cognitive Level: Analyzing REF: p. 1608
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. The nurse is caring for a 14-year-old child with juvenile idiopathic arthritis (JIA). What
clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Erythema over joints
b. Soft tissue contractures
c. Swelling in multiple joints
d. Morning stiffness of the joints
e. Loss of motion in the affected joints
ANS: B, C, D, E
Whether single or multiple joints are involved, stiffness, swelling, and loss of motion develop in
the affected joints in JIA. The swelling results from soft tissue edema, joint effusion, and
synovial thickening. The affected joints may be warm and tender to the touch, but it is not
uncommon for pain not to be reported. The limited motion early in the disease is a result of
muscle spasm and joint inflammation; later it is caused by ankylosis or soft tissue contracture.
Morning stiffness of the joint(s) is characteristic and present on arising in the morning or after
inactivity. Erythema is not typical, and a warm, painful, red joint is always suspect for infection.
DIF: Cognitive Level: Analyzing REF: p. 1602
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The school nurse recognizes that the adverse effects of performance-enhancing substances can
include what? (Select all that apply.)
a. Depression
b. Dehydration
c. Hypotension
d. Aggressiveness
e. Changes in libido
ANS: A, D, E
Mood changes have been observed as adverse effects of using performance-enhancing
substances, including aggressiveness, changes in libido, depression, anxiety, and psychosis. Fluid
retention, not dehydration, and hypertension, not hypotension, are adverse effects of
performance-enhancing substances.
DIF: Cognitive Level: Analyzing REF: p. 1582
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
COMPLETION
1. The health care provider has prescribed sulfasalazine (Azulfidine) 5 mg/kg PO per dose twice
a day for a child with juvenile arthritis. The child weighs 55 lb. The nurse is preparing to
administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record
your answer below in a whole number.
________
ANS:
125
The correct calculation is:
55 lb/2.2 kg = 25 kg
Dose of Azulfidine is 5 mg/kg
5 mg 25 = 125 mg
DIF: Cognitive Level: Applying REF: p. 1604
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
2. The health care provider has prescribed cyclosporin (Sandimmune) 5 mg/kg/day PO divided
twice daily for a child with juvenile arthritis. The child weighs 110 lb. The nurse is preparing to
administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record
your answer in a whole number.
_________
ANS:
125
The correct calculation is:
110 lb/2.2 kg = 50 kg
Dose of Sandimmune is 5 mg/kg/day divided bid
5 mg 50 = 250 mg/day
250 mg/2 = 125 mg for one dose
DIF: Cognitive Level: Applying REF: p. 1602
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3. The health care provider has prescribed azathioprine (Imuran) 1 mg/kg/day PO for a child with
juvenile arthritis. The child weighs 77 lb. The nurse is preparing to administer the daily dose.
Calculate the dose the nurse should administer in milligrams. Record your answer below in a
whole number.
_______
ANS:
35
The correct calculation is:
77 lb/2.2 kg = 35 kg
Dose of Imuran is 1 mg/kg/day
1 mg 35 = 35 mg for the daily dose
DIF: Cognitive Level: Applying REF: p. 1609
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
4. The health care provider has prescribed hydroxychloroquine (Plaquenil) 5 mg/kg/day PO
divided bid for a child with systemic lupus erythematosus. The child weighs 66 lb. The nurse is
preparing to administer the 0900 dose. Calculate the dose the nurse should administer in
milligrams. Record your answer below in a whole number.
_________
ANS:
75
The correct calculation is:
66 lb/2.2 kg = 30 kg
Dose of Plaquenil is 5 mg/kg/day divided bid
5 mg 30 = 150 mg
150 mg/2 = 75 mg
DIF: Cognitive Level: Applying REF: p. 1609
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
MATCHING
Match the type of fracture to its definition.
a. Transverse
b. Oblique
c. Spiral
d. Comminuted
1. Slanting and circular, twisting around the bone shaft
2. Small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue
3. Crosswise at right angles to the long axis of the bone
4. Slanting but straight between a horizontal and a perpendicular direction
The Child with Endocrine Dysfunction
MULTIPLE CHOICE
1. Homeostasis in the body is maintained by what is collectively known as the neuroendocrine
system. What is the name of the nervous system that is involved?
a. Central
b. Skeletal
c. Peripheral
d. Autonomic
ANS: D
The autonomic nervous system (composed of the sympathetic and parasympathetic systems)
controls involuntary functions. In combination with the endocrine system, it maintains
homeostasis. The central, skeletal, and peripheral subdivisions of the nervous system are not part
of the neuroendocrine system.
DIF: Cognitive Level: Understanding REF: p. 1494
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing
considerations should be based on which knowledge?
a. Therapy is most successful if it is started during adolescence.
b. Replacement therapy requires daily subcutaneous injections.
c. Hormonal supplementation will be required throughout childs lifetime.
d. Treatment is considered successful if children attain full stature by adolescence.
ANS: B
Additional support is required for children who require hormone replacement therapy, such as
preparation for daily subcutaneous injections and education for self-management during the
school-age years. Young children, obese children, and those who are severely GH deficient have
the best response to therapy. Replacement therapy is not needed after attaining final height. The
children are no longer GH deficient. When therapy is successful, children can attain their actual
or near-final adult height at a slower rate than their peers.
DIF: Cognitive Level: Analyzing REF: p. 1499 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
3. A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time
for the GH to be administered?
a. At bedtime
b. After meals
c. Before meals
d. After arising in morning
ANS: A
Injections are best given at bedtime to more closely approximate the physiologic release of GH.
After meals, before meals, and after arising in the morning do not parallel the physiologic release
of the hormone.
DIF: Cognitive Level: Applying REF: p. 1499
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
4. What is a condition that can result if hypersecretion of growth hormone (GH) occurs after
epiphyseal closure?
a. Cretinism
b. Dwarfism
c. Gigantism
d. Acromegaly
ANS: D
Excess GH after closure of the epiphyseal plates results in acromegaly. Cretinism is associated
with hypothyroidism. Dwarfism is the condition of being abnormally small. Gigantism occurs
when there is hypersecretion of GH before the closure of the epiphyseal plates.
DIF: Cognitive Level: Understanding REF: p. 1501
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. Peripheral precocious puberty (PPP) differs from central precocious puberty (CPP) in which
manner?
a. PPP results from a central nervous system (CNS) insult.
b. PPP occurs more frequently in girls.
c. PPP may be viewed as a variation in sexual development.
d. PPP results from hormonal stimulation of the hypothalamic gonadotropin-releasing hormone (Gn-RH).
ANS: C
PPP may be viewed as a variation in sexual development. PPP results from hormone stimulation
other than the hypothalamic Gn-RH. Isolated manifestations of secondary sexual development
occur. PPP can be missed if these changes are viewed as variations in pubertal onset. CPP results
from CNS insult, occurs more frequently in girls, and results from hormonal stimulation of the
hypothalamic Gn-RH.
DIF: Cognitive Level: Understanding REF: p. 1502
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. A child will start treatment for central precocious puberty. What synthetic hormone will be
injected?
a. Thyrotropin
b. Gonadotropins
c. Somatotropic hormone
d. Luteinizing hormonereleasing hormone
ANS: D
Precocious puberty of central origin is treated with monthly subcutaneous injections of
luteinizing hormonereleasing hormone, which regulates pituitary secretions. Thyrotropin,
gonadotropins, and somatotropic hormone are not the appropriate therapies for precocious
puberty.
DIF: Cognitive Level: Understanding REF: p. 1502
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
7. The nurse is planning care for a child recently diagnosed with diabetes insipidus (DI). What
intervention should be included?
a. Encourage the child to wear medical identification.
b. Discuss with the child and family ways to limit fluid intake.
c. Teach the child and family how to do required urine testing.
d. Reassure the child and family that this is usually not a chronic or life-threatening illness.
ANS: A
DI is a potentially life-threatening disorder if the voluntary demand for fluid is suppressed or the
child does not have access to fluids. Medical alert identification should be worn. Fluid intake is
not restricted in children with DI. The child is unable to concentrate urine and can rapidly
become dehydrated. Fluid intake may be limited during diagnosis, when the lack of intake will
result in decreased urinary output and dehydration. Urine testing is not required in DI. Changes
in body weight provide information about approximate fluid balance. This is a lifelong disorder
that requires supplemental vasopressin throughout life.
DIF: Cognitive Level: Applying REF: p. 1502 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
8. Intranasal administration of desmopressin acetate (DDAVP) is used to treat which condition?
a. Hypopituitarism
b. Diabetes insipidus (DI)
c. Syndrome of inappropriate antidiuretic hormone (SIADH)
d. Acute adrenocortical insufficiency
ANS: B
DDAVP is the treatment of choice for DI. It is administered intranasally through a flexible tube.
The childs response pattern is variable, with effectiveness lasting from 6 to 24 hours.
DIF: Cognitive Level: Understanding REF: p. 1503
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. What nursing care should be included for a child diagnosed with syndrome of inappropriate
antidiuretic hormone (SIADH)?
a. Maintain the child NPO (nothing by mouth).
b. Turn the child frequently.
c. Restrict fluids.
d. Encourage fluids.
ANS: C
Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid volume
and decreases serum osmolarity with a progressive reduction in sodium concentration. The
immediate management of the child is to restrict fluids but not food. Frequently turning the child
is not necessary unless the child is unresponsive. Encouraging fluids will worsen the childs
condition.
DIF: Cognitive Level: Analyzing REF: p. 1504 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
10. What is a common clinical manifestation of juvenile hypothyroidism?
a. Insomnia
b. Diarrhea
c. Dry skin
d. Rapid growth
ANS: C
Dry skin, mental decline, and myxedematous skin changes are associated with juvenile
hypothyroidism. Children with hypothyroidism often have sleepiness, constipation, and
decelerated growth.
DIF: Cognitive Level: Understanding REF: p. 1505
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. A goiter is an enlargement or hypertrophy of which gland?
a. Thyroid
b. Adrenal
c. Anterior pituitary
d. Posterior pituitary
ANS: A
A goiter is an enlargement or hypertrophy of the thyroid gland. Goiter is not associated with the
adrenal, anterior pituitary, or posterior pituitary secretory organs.
DIF: Cognitive Level: Understanding REF: p. 1505
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
12. Exophthalmos (protruding eyeballs) may occur in children with which condition?
a. Hypothyroidism
b. Hyperthyroidism
c. Hypoparathyroidism
d. Hyperparathyroidism
ANS: B
Exophthalmos is associated with hyperthyroidism. Hypothyroidism, hypoparathyroidism, and
hyperparathyroidism are not associated with exophthalmos.
DIF: Cognitive Level: Understanding REF: p. 1507
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. A child is receiving propylthiouracil for the treatment of hyperthyroidism (Graves disease).
The parents and child should be taught to recognize and report which sign or symptom
immediately?
a. Fatigue
b. Weight loss
c. Fever, sore throat
d. Upper respiratory tract infection
ANS: C
Children being treated with propylthiouracil must be carefully monitored for the side effects of
the drug. Parents must be alerted that sore throat and fever accompany the grave complication of
leukopenia. These symptoms should be immediately reported. Fatigue and weight loss are
manifestations of hyperthyroidism. Their presence may indicate that the drug is not effective but
does not require immediate evaluation. Upper respiratory tract infections are most likely viral in
origin and not a sign of leukopenia.
DIF: Cognitive Level: Applying REF: p. 1507
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
14. The school nurse practitioner is consulted by a fifth-grade teacher about a student who has
become increasingly inattentive and hyperactive in the classroom. The nurse notes that the childs
weight has changed from the 50th percentile to the 30th percentile. The nurse is concerned about
possible hyperthyroidism. What additional sign or symptom should the nurse anticipate?
a. Skin that is cool and dry
b. Blurred vision and loss of acuity
c. Running and being active during recess
d. Decreased appetite and food intake
ANS: B
Visual disturbances such as loss of visual acuity and blurred vision are associated with
hyperthyroidism. They may occur before the actual onset of other symptoms. The childs skin is
usually warm, flushed, and moist. Although the signs of hyperthyroidism include excessive
motion, irritability, hyperactivity, short attention span, and emotional lability, these children are
easily fatigued and require frequent rest periods. Children with hyperthyroidism have increased
food intake. Even with voracious appetites, weight loss occurs.
DIF: Cognitive Level: Applying REF: p. 1507
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
15. A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be
advised to watch for which signs or symptoms of vitamin D toxicity?
a. Headache and seizures
b. Weakness and lassitude
c. Anorexia and insomnia
d. Physical restlessness, voracious appetite without weight gain
ANS: B
Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for
weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal impairment is
manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign of vitamin D
toxicity, but seizures are not. Anorexia and insomnia are not characteristic of vitamin D toxicity.
Physical restlessness and a voracious appetite with weight loss are manifestations of
hyperthyroidism.
DIF: Cognitive Level: Applying REF: p. 1509
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
16. Glucocorticoids, mineralocorticoids, and sex steroids are secreted by which gland?
a. Thyroid gland
b. Adrenal cortex
c. Anterior pituitary
d. Parathyroid glands
ANS: B
The glucocorticoids, mineralocorticoids, and sex steroids are secreted by the adrenal cortex. The
thyroid gland produces thyroid hormone and thyrocalcitonin. The anterior pituitary produces
hormones such as growth hormone, thyroid-stimulating hormone, adrenocorticotropic hormone,
gonadotropin, prolactin, and melanocyte-stimulating hormone. The parathyroid glands produce
parathyroid hormone.
DIF: Cognitive Level: Understanding REF: p. 1510
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
17. Congenital adrenal hyperplasia (CAH) is suspected in a newborn because of ambiguous
genitalia. The parents are appropriately upset and concerned about their childs gender. In
teaching the parents about CAH, what should the nurse explain?
a. Reconstructive surgery as a female is preferred.
b. Sexual assignment should wait until genetic sex is determined.
c. Prenatal masculinization will strongly influence the childs development.
d. The child should be raised as a boy because of the presence of a penis and scrotum.
ANS: B
It is preferable to raise the child according to genetic sex. With hormone replacement and
surgical intervention if needed, genetically female children achieve satisfactory results in
reversing virilism and achieving normal puberty and ability to conceive. Reconstructive surgery
as a female is only preferred for infants who are genetically female. Infants who are genetically
male should be given hormonal supplementation. Sex assignment and rearing depend on
psychosocial influences, not on genetic sex hormone influences during fetal life. It is not advised
to raise the child as a boy because of the presence of a penis and scrotum unless the child is
genetically male. If a genetic female, the child will be sterile and may never be able to function
satisfactorily in a heterosexual relationship.
DIF: Cognitive Level: Applying REF: p. 1517
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
18. What form of diabetes is characterized by destruction of pancreatic beta cells, resulting in
insulin deficiency?
a. Type 1 diabetes
b. Type 2 diabetes
c. Gestational diabetes
d. Maturity-onset diabetes of the young (MODY)
ANS: A
Type 1 diabetes is characterized by the destruction of the pancreatic beta cells, which leads to
absolute insulin deficiency. Type 2 diabetes results usually from insulin resistance. The
pancreatic beta cells are not destroyed in gestational diabetes. MODY is an autosomal dominant
monogenetic defect in beta cell function that is characterized by impaired insulin secretion with
minimum or no defects in insulin action.
DIF: Cognitive Level: Understanding REF: p. 1519
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
19. What statement is characteristic of type 1 diabetes mellitus?
a. Onset is usually gradual.
b. Ketoacidosis is infrequent.
c. Peak age incidence is 10 to 15 years.
d. Oral agents are available for treatment.
ANS: C
Type 1 diabetes mellitus typically usually has its onset before the age of 20 years, with a peak
incidence between ages 10 and 15 years. Type 1 has an abrupt onset, in contrast to type 2, which
has a more gradual appearance. Ketoacidosis occurs when insulin is unavailable and the body
uses sources other than glucose for cellular metabolism. Ketoacidosis is more common in type 1
diabetes than in type 2. At this time, oral agents are available only for type 2 diabetes.
DIF: Cognitive Level: Analyzing REF: p. 1520
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
20. What clinical manifestation is considered a cardinal sign of diabetes mellitus?
a. Nausea
b. Seizures
c. Impaired vision
d. Frequent urination
ANS: D
Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures are
not clinical manifestations of diabetes mellitus. Impaired vision is a long-term complication of
the disease.
DIF: Cognitive Level: Understanding REF: p. 1523
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
21. What blood glucose measurement is most likely associated with diabetic ketoacidosis?
a. 185 mg/dl
b. 220 mg/dl
c. 280 mg/dl
d. 330 mg/dl
ANS: D
Diabetic ketoacidosis is a state of relative insulin insufficiency and may include the presence of
hyperglycemia, a blood glucose level greater than or equal to 330 mg/dl; 185, 220, and 280
mg/dl are values that are too low for the definition of ketoacidosis.
DIF: Cognitive Level: Understanding REF: p. 1530
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise.
What effect does exercise have on a type 1 diabetic?
a. Exercise increases blood glucose.
b. Extra insulin is required during exercise.
c. Additional snacks are needed before exercise.
d. Excessive physical activity should be restricted.
ANS: C
Exercise lowers blood glucose levels, decreasing the need for insulin. Extra snacks are provided
to maintain the blood glucose levels. Exercise is encouraged and not restricted unless indicated
by other health conditions.
DIF: Cognitive Level: Applying REF: p. 1527
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
23. A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-
releasing sugar should be followed by which dietary intervention?
a. Sports drink and fruit
b. Glucose tabs and protein
c. Glass of water and crackers
d. Milk and peanut butter on bread
ANS: D
Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a
complex carbohydrate and protein. Milk supplies lactose and a more prolonged action from the
protein. The bread is a complex carbohydrate, which with the peanut butter provides a sustained
action. The sports drink contains primarily simple carbohydrates. The fruit contains additional
carbohydrates. A protein source is needed for sustained action. The glucose tabs are simple
carbohydrates. Complex carbohydrates are needed with the protein. Crackers are a complex
carbohydrate, but protein is needed to stabilize the blood sugar.
DIF: Cognitive Level: Applying REF: p. 1528 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
24. A 20-kg (44-lb) child in ketoacidosis is admitted to the pediatric intensive care unit. What
order should the nurse not implement until clarified with the physician?
a. Weigh on admission and daily.
b. Replace fluid volume deficit over 48 hours.
c. Begin intravenous line with D5 0.45% normal saline with 20 mEq of potassium chloride.
d. Give intravenous regular insulin 2 units/kg/hr after initial rehydration bolus.
ANS: C
The initial hydrating solution is 0.9% normal saline. Potassium is not given until the child is
voiding 25 ml/hr, demonstrating adequate renal function. After initial rehydration and insulin
administration, then potassium is given. Dextrose is not given until blood glucose levels are
between 250 and 300 mg/dl. An accurate, current weight is essential for determination of the
amount of fluid loss and as a basis for medication dosage. Replacing fluid volume deficit over 48
hours is the current recommendation in diabetic ketoacidosis in children. Cerebral edema is a
risk of more rapid administration. Intravenous regular insulin 2 units/kg/hr after initial
rehydration bolus is the recommended insulin administration for a child of this weight. Only
regular insulin can be given intravenously, and it is given after initial fluid volume expansion.
DIF: Cognitive Level: Applying REF: p. 1530
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
25. What clinical manifestation occurs with hypoglycemia?
a. Lethargy
b. Confusion
c. Nausea and vomiting
d. Weakness and dizziness
ANS: D
Some of the clinical manifestations of hypoglycemia include weakness; dizziness; difficulty
concentrating, speaking, focusing, and coordinating; sweating; and pallor. Lethargy, confusion,
and nausea and vomiting are manifestations of hyperglycemia.
DIF: Cognitive Level: Understanding REF: p. 1537
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
26. A 12-year-old girl is newly diagnosed with diabetes when she develops ketoacidosis. How
should the nurse structure a successful education program?
a. Essential information is presented initially.
b. Teaching should take place in the childs semiprivate room.
c. Education is focused toward the parents because the child is too young.
d. All information needed for self-management of diabetes is taught at once.
ANS: A
Diagnosis of type 1 diabetes can be traumatic for the child and family. Most families are not
psychologically ready for the complex teaching that is needed for self-management. Most
structured diabetes education programs begin with essential or survival information followed by
the complex background material when the family is better able to learn. Teaching can take place
either as an outpatient or as an inpatient. The actual teaching area should be free from
distractions that would interfere with learning. A semiprivate room would have many individuals
entering and leaving the room, causing distraction. A 12-year-old child who is cognitively age
appropriate needs to be included in the educational process. Most children older than the age of 8
years can be involved in blood glucose monitoring and insulin administration. Teaching all
information needed for self-management of diabetes at once would be too overwhelming for a
family in crisis.
DIF: Cognitive Level: Applying REF: p. 1524
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
27. The nurse is discussing with a child and family the various sites used for insulin injections.
What site usually has the fastest rate of absorption?
a. Arm
b. Leg
c. Buttock
d. Abdomen
ANS: D
The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate
of absorption but a short duration. The leg has a slow rate of absorption but a long duration. The
buttock has the slowest rate of absorption and the longest duration.
DIF: Cognitive Level: Applying REF: p. 1525
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
28. The nurse is teaching an adolescent about giving insulin injections. The adolescent asks if the
disposable needles and syringes can be used more than once. The nurses response should be
based on which knowledge?
a. It is unsafe.
b. It is acceptable for up to 24 hours.
c. It is acceptable for families with very limited resources.
d. It is suitable for up to 3 days if stored in the refrigerator.
ANS: D
Bacterial counts are unaffected if insulin syringes are handled in an aseptic manner and stored in
the refrigerator between use. The syringes can be used up to 3 days and result in a considerable
cost savings. Bacterial counts remain low for up to 72 hours with proper technique. The familys
resources are not an issue; if a practice is unsafe, the family should not be encouraged to
endanger the child by reusing equipment.
DIF: Cognitive Level: Applying REF: p. 1526
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
29. A preadolescent has maintained good glycemic control of his type 1 diabetes through the
school year. During summer vacation, he has had repeated episodes of hypoglycemia. What
additional teaching is needed?
a. Carbohydrates in the diet need to be replaced with protein.
b. Additional snacks are needed to compensate for increased activity.
c. The child needs to decrease his activity level to minimize episodes of hypoglycemia.
d. Insulin dosage should be increased to compensate for a change in activity level.
ANS: B
Most children have a different schedule during summer vacation. The increased activity and
exercise reduce insulin resistance and increase glucose utilization. Additional snacks should be
eaten before physical activity to increase carbohydrates and protein and compensate for
increased activity. Physical activity should always be encouraged if the child is capable. The
benefits include improved glucose utilization and decreased insulin requirements. In consultation
with the practitioner, insulin dosage may need to be decreased because of improved glucose
utilization.
DIF: Cognitive Level: Applying REF: p. 1526
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
30. To help an adolescent deal with diabetes, the nurse needs to consider which characteristic of
adolescence?
a. Desire to be unique
b. Preoccupation with the future
c. Need to be perfect and similar to peers
d. Awareness of peers that diabetes is a severe disease
ANS: C
Adolescence is a time when the individual has a need to be perfect and similar to peers. Having
diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they
desire to fit in with the peer group. An adolescent is usually not future oriented. Awareness of
peers that diabetes is a severe disease would further alienate the adolescent with diabetes. The
peer group would focus on the differences.
DIF: Cognitive Level: Analyzing REF: p. 1538
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
31. An adolescent diabetic is admitted to the emergency department for treatment of
hyperglycemia and pneumonia. What are characteristics of diabetic hyperglycemia?
a. Cold, clammy skin and lethargy
b. Hunger and hypertension
c. Thirst, being flushed, and fruity breath
d. Disorientation and pallor
ANS: C
The signs of hyperglycemia are thirst, being flushed, and fruity breath. The skin is not cold or
clammy, and there is not hunger and hypertension. Disorientation and pallor are signs of
hypoglycemia.
DIF: Cognitive Level: Understanding REF: p. 1528
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
32. A school-age child with diabetes gets 30 units of NPH insulin at 0800. According to when
this insulin peaks, the child should be at greatest risk for a hypoglycemic episode between when?
a. Lunch and dinner
b. Breakfast and lunch
c. 0830 to his midmorning snack
d. Bedtime and breakfast the next morning
ANS: A
Intermediate-acting (NPH and Lente) insulins reach the blood 2 to 6 hours after injection. The
insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours.
DIF: Cognitive Level: Analyzing REF: p. 1525
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
33. The nurse is teaching the parent of a preschool child how to administer the childs insulin
injection. The child will be receiving 2 units of regular insulin and 12 units of NPH insulin every
morning. What should the parent be taught?
a. Draw the insulin in separate syringes.
b. Draw the regular insulin first and then the NPH into the same syringe.
c. Draw the NPH insulin first and then the regular into the same syringe.
d. Check blood sugar first, and if below 120, hold the regular insulin and give the NPH.
ANS: B
To obtain maximum benefit from mixing insulins, the recommended practice is to (1) inject the
measured amount of air (equivalent to the dosage) into the long-acting insulin; (2) inject the
measured amount of air into the rapid-acting (clear) insulin and, without removing the needle;
(3) withdraw the clear insulin; and (4) insert the needle (already containing the clear insulin) into
the long-acting (cloudy) insulin and then withdraw the desired amount. The blood sugar may be
checked before giving the insulin, but the prescribed dose should not be withheld if the blood
sugar is 120.
DIF: Cognitive Level: Applying REF: p. 1535
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
34. What statement applies to the current focus of the dietary management of children with
diabetes?
a. Measurement of all servings of food is vital for control.
b. Daily calculate specific amounts of carbohydrates, fats, and proteins.
c. The number of calories for carbohydrates remains constant on a daily basis; protein and fat calories are liberal.
d.
The intake ensures day-to-day consistency in total calories, protein, carbohydrates, and moderate fat while allowing for a
wide variety of foods.
ANS: D
Essentially the nutritional needs of children with diabetes are no different from those of healthy
children. Children with diabetes need no special foods or supplements. They need sufficient
calories to balance daily expenditure for energy and to satisfy the requirement for growth and
development.
DIF: Cognitive Level: Analyzing REF: p. 1526
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
35. During the summer many children are more physically active. What changes in the
management of the child with diabetes should be expected as a result of more exercise?
a. food intake
b. food intake
c. risk of hyperglycemia
d. risk of insulin reaction
ANS: A
Exercise is encouraged and never restricted unless indicated by other health conditions. Exercise
lowers blood glucose levels, depending on the intensity and duration of the activity.
Consequently, exercise should be included as part of diabetes management, and the type and
amount of exercise should be planned around the childs interests and capabilities. However, in
most instances, childrens activities are unplanned, and the resulting decrease in blood glucose
can be compensated for by providing extra snacks before (and, if the exercise is prolonged,
during) the activity. In addition to a feeling of well-being, regular exercise aids in utilization of
food and often results in a reduction of insulin requirements.
DIF: Cognitive Level: Analyzing REF: p. 1527
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
36. Prolonged steroid therapy has caused a child to have Cushing syndrome. To lessen the
cushingoid effects, the steroid should be administered at which time?
a. In the PM
b. After lunch
c. QD in the AM
d. QOD in the AM
ANS: D
When cushingoid features are caused by steroid therapy, the effects may be lessened with
administration of the drug early in the morning and on an alternate-day basis. Giving the drug
early in the day maintains the normal diurnal pattern of cortisol secretion. If given during the
evening, it is more likely to produce symptoms because endogenous cortisol levels are normally
low and the additional supply exerts more pronounced effects. An alternate-day schedule allows
the anterior pituitary an opportunity to maintain more normal hypothalamicpituitaryadrenal
control mechanisms.
DIF: Cognitive Level: Applying REF: p. 1515
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
37. The thyroid-stimulating hormone (TSH) increases secretion in response to which hormone?
a. Low levels of circulating thyroid hormone
b. High levels of circulating thyroid hormone
c. Low levels of circulating adrenocorticotropic hormone
d. High levels of circulating adrenocorticotropic hormone
ANS: A
As blood concentrations of the target hormones reach normal levels, a negative message is sent
to the anterior pituitary to inhibit release of the tropic hormone. For example, TSH responds to
low levels of circulating TH. As blood levels of TH reach normal concentrations, a negative
feedback message is sent to the anterior pituitary, resulting in diminished release of TSH.
Adrenocorticotropic stimulates the adrenals to secrete glucocorticoids.
DIF: Cognitive Level: Understanding REF: p. 1494
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
38. The nurse is caring for an adolescent with anorexia nervosa. What pituitary dysfunction
should the nurse assess for in the adolescent?
a. Hypopituitarism
b. Pituitary hyperfunction
c. Hyperplasia of the pituitary cells
d. Overproduction of the anterior pituitary hormones
ANS: A
Anorexia nervosa can cause hypopituitarism. It does not cause the hyperfunction of the pituitary,
hyperplasia of the pituitary cells, or overproduction of the anterior pituitary hormones.
DIF: Cognitive Level: Understanding REF: p. 1496
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
39. The clinic nurse is assessing a child with hypopituitarism. Hypopituitarism can lead to which
disorder?
a. Gigantism
b. Hyperthyroidism
c. Cushing syndrome
d. Growth hormone deficiency
ANS: D
Hypopituitarism can lead to a growth hormone deficiency. An overproduction of the anterior
pituitary hormones can result in gigantism (caused by excess growth hormone production during
childhood), hyperthyroidism, or hypercortisolism (Cushing syndrome).
DIF: Cognitive Level: Understanding REF: p. 1500
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
40. The nurse is assisting with a growth hormone stimulation test for a child with short stature.
What should the nurse monitor closely on this child during the test?
a. Hypotension
b. Tachycardia
c. Hypoglycemia
d. Nausea and vomiting
ANS: A
Patients receiving clonidine (Catapres) for a growth hormone stimulation test require close blood
pressure monitoring for hypotension. Tachycardia, hypoglycemia, and nausea and vomiting do
not occur with Catapres administered for a growth hormone stimulation test.
DIF: Cognitive Level: Applying REF: p. 1500
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
41. The nurse is preparing to administer a prescribed dose of desmopressin acetate (DDAVP)
intramuscularly (IM) to a child with diabetes insipidus. What action should the nurse take before
drawing the medication into a syringe?
a. Mix the medication with sterile water.
b. Mix the medication with sterile normal saline.
c. Have another nurse double-check the medication dose.
d. Hold the medication under warm water for 10 to 15 minutes and then shake vigorously.
ANS: D
To be effective, vasopressin must be thoroughly mixed in the oil by being held under warm
running water for 10 to 15 minutes and shaken vigorously before being drawn into the syringe. If
this is not done, the oil may be injected minus the antidiuretic hormone. Small brown particles,
which indicate drug dispersion, must be seen in the suspension.
DIF: Cognitive Level: Applying REF: p. 1503
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
42. The nurse is taking care of a child who had a thyroidectomy. The nurse recognizes what as a
positive Chvostek sign?
a. Paresthesia occurring in feet and toes
b. Frequent sharp flexion of wrist and ankle joints
c. Carpal spasm elicited by pressure applied to the nerves of the upper arm
d. Facial muscle spasm elicited by tapping the facial nerve in the region of the parotid gland
ANS: D
A positive Chvostek sign is a facial muscle spasm that is elicited by tapping the facial nerve in
the region of the parotid gland. Paresthesia occurring in the feet and toes and frequent sharp
flexion of the wrist and ankle joints can be signs of hypoparathyroidism but are not part of a
positive Chvostek sign. Carpal spasm elicited by pressure applied to nerves of the upper arm is
called a positive Trousseau sign.
DIF: Cognitive Level: Analyzing REF: p. 1508
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
43. A child is having tests done to determine parathyroid function. The clinic nurse knows that
the parathyroid hormone (PTH) regulates the homeostasis of what in the serum?
a. Sodium
b. Calcium
c. Potassium
d. Magnesium
ANS: B
The parathyroid glands secrete PTH. Along with vitamin D and calcitonin, PTH regulates the
homeostasis of serum calcium concentrations.
DIF: Cognitive Level: Understanding REF: p. 1508
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
44. The nurse is caring for a child after a parathyroidectomy. What medication should the nurse
have available if hypocalcemia occurs?
a. Insulin
b. Calcium gluconate
c. Propylthiouracil (PTU)
d. Cortisone (hydrocortisone)
ANS: B
Because hypocalcemia is a potential complication after a parathyroidectomy, observing for signs
of tetany, instituting seizure precautions, and having calcium gluconate available for emergency
use are part of the nursing care.
DIF: Cognitive Level: Applying REF: p. 1510
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The nurse is preparing a community outreach program for adolescents about the characteristic
differences between type 1 and type 2 diabetes mellitus (DM). What concepts should the nurse
include? (Select all that apply.)
a. Type 1 DM has an abrupt onset.
b. Type 1 DM is often controlled with oral glucose agents.
c. Type 1 DM occurs primarily in whites.
d. Type 2 DM always requires insulin therapy.
e. Type 2 DM frequently has a familial history.
f. Type 2 DM occurs in people who are overweight.
ANS: A, C, E, F
Characteristics of type 1 DM include having an abrupt onset, primarily occurring in whites, and
not being controlled with oral glucose agents (insulin is required for therapy). Type 2 DM
frequently has a familial history, occurs in people who are overweight, and does not always
require insulin therapy (it is used in 20% to 30% of patients).
DIF: Cognitive Level: Analyzing REF: p. 1520
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
2. The nurse is preparing to admit a 9-year-old child with syndrome of inappropriate antidiuretic
hormone (SIADH). What interventions should the nurse include in the childs care plan? (Select
all that apply.)
a. Provide a low-sodium, low-fat diet.
b. Initiate seizure precautions.
c. Weigh daily at the same time each day.
d. Encourage intake of 1 l of fluid per day.
e. Measure intake and output hourly.
ANS: B, C, E
Nursing care of the child with SIADH includes placing the child on seizure precautions,
obtaining a daily weight at the same time each day, and accurately measuring the childs intake
and output. The nurse does not need to provide a low-sodium, low-fat diet because there are no
diet restrictions. The child would be on fluid precautions to avoid fluid overload, so 1 l of fluid
would not be encouraged.
DIF: Cognitive Level: Applying REF: p. 1505
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3. The nurse is planning to admit a 14-year-old adolescent with Cushing syndrome. What clinical
manifestations should the nurse expect to observe in this child? (Select all that apply.)
a. Truncal obesity
b. Decreased pubic hair
c. Petechial hemorrhage
d. Hyperpigmentation of elbows
e. Facial plethora
f. Headache and weakness
ANS: A, C, E
Clinical manifestations of Cushing syndrome include truncal obesity, petechial hemorrhage, and
facial plethora. Decreased pubic and axillary hair; hyperpigmentation of elbows, knees, and
wrists; and headache and weakness are clinical manifestations of adrenocortical insufficiency.
DIF: Cognitive Level: Applying REF: p. 1514
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. The nurse is teaching the family of a child with type 1 diabetes about insulin. What should the
nurse include in the teaching session?(Select all that apply.)
a. Unopened vials are good for 60 days.
b. Diabetic supplies should not be left in a hot environment.
c. Insulin can be placed in the freezer if not used every day.
d. After it has been opened, insulin is good for up to 28 to 30 days.
e. Insulin bottles that have been opened should be stored at room temperature or refrigerated.
ANS: B, D, E
Insulin bottles that have been opened (i.e., the stopper has been punctured) should be stored at
room temperature or refrigerated for up to 28 to 30 days. After 1 month, these vials should be
discarded. Unopened vials should be refrigerated and are good until the expiration date on the
label. Diabetic supplies should not be left in a hot environment. Insulin need not be refrigerated
but should be maintained at a temperature between 15 and 29.5 C (59 and 85 F). Freezing
renders insulin inactive.
DIF: Cognitive Level: Applying REF: p. 1534
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse is caring for a child with an anterior pituitary tumor. What hormones are secreted by
the anterior pituitary? (Select all that apply.)
a. Oxytocin
b. Luteinizing hormone
c. Antidiuretic hormone
d. Thyroid-stimulating hormone
e. Adrenocorticotrophic hormone
ANS: B, D, E
The anterior pituitary is responsible for secreting the following hormones: growth hormone,
thyroid-stimulating hormone, adrenocorticotrophic hormone, follicle-stimulating hormone,
luteinizing hormone, and prolactin. The posterior pituitary secretes antidiuretic hormone and
oxytocin.
DIF: Cognitive Level: Analyzing REF: p. 1495
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. The nurse is preparing to assist with a growth hormone provocative test for a child with short
stature. The nurse recognizes that which pharmacologics should be used to provoke the release of
growth hormone (GH)? (Select all that apply.)
a. Larodopa (levodopa)
b. Clonidine (Catapres)
c. Propranolol (Inderal)
d. Cortisone (hydrocortisone)
e. Biosynthetic growth hormone
ANS: A, B, C
GH stimulation, or provocative testing, involves the use of pharmacologics to provoke the
release of GH either directly or indirectly. Provocative testing involves the use of
neuromodulators such as levodopa or agents such as clonidine, arginine, insulin, propranolol, or
glucagon followed by the measurement GH blood levels. Cortisone is given to replace hormone
deficiencies that can occur with GH deficiency. Biosynthetic GH is used to treat GH deficiency.
DIF: Cognitive Level: Applying REF: p. 1499 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
7. The clinic nurse is assessing a child with central precocious puberty. What conditions can
cause central precocious puberty? (Select all that apply.)
a. Trauma
b. Neoplasms
c. Radiotherapy
d. Exogenous sex hormones
e. Primary hypothyroidism
ANS: A, B, C
Trauma, neoplasms, and radiotherapy can be the cause of central precocious puberty. Exogenous
sex hormones and primary hypothyroidism can cause peripheral precocious puberty.
DIF: Cognitive Level: Understanding REF: p. 1502
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The nurse is planning to admit a 10-year-old child with syndrome of inappropriate antidiuretic
hormone (SIADH). What clinical manifestations should the nurse expect to observe in this
child? (Select all that apply.)
a. Polyuria
b. Anorexia
c. Polydipsia
d. Irritability
e. Stomach cramps
ANS: B, D, E
Clinical signs of SIADH are directly related to fluid retention and hyponatremia. When cells in
the brain are exposed to too much water as opposed to sodium, swelling occurs. When serum
sodium levels are diminished to 120?9?mEq/l, affected children may display anorexia, nausea,
vomiting, stomach cramps, irritability, and personality changes. Polyuria and polydipsia are
manifestations of diabetes insipidus.
DIF: Cognitive Level: Applying REF: p. 1504
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. The nurse is planning to admit a 12-year-old with Graves disease (GD). What clinical
manifestations should the nurse expect to observe in this child? (Select all that apply.)
a. Insomnia
b. Irritability
c. Tonic rigidity
d. Hyperactivity
e. Muscle cramps
ANS: A, B, D
Signs and symptoms of hyperthyroidism develop gradually, with an interval between onset and
diagnosis of approximately 6 to 12 months. Clinical features include irritability, hyperactivity,
short attention span, tremors, insomnia, and emotional lability. Tonic rigidity and muscle cramps
are signs of hypoparathyroidism.
DIF: Cognitive Level: Applying REF: p. 1507
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The nurse is planning to admit an 8-year-old child with hypoparathyroidism. What clinical
manifestations should the nurse expect to observe in this child? (Select all that apply.)
a. Muscle cramps
b. Positive Chvostek sign
c. Emotional lability
d. Laryngeal spasms
e. Short attention span
ANS: A, B, D
Clinical manifestations of hypoparathyroidism include muscle cramps, positive Chvostek sign,
and laryngeal spasms. Emotional lability and short attention span are signs of Graves disease.
DIF: Cognitive Level: Applying REF: p. 1509
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. What are characteristics of diabetic ketoacidosis? (Select all that apply.)
a. Pallor
b. Acidosis
c. Bradypnea
d. Dehydration
e. Electrolyte imbalance
ANS: B, D, E
Characteristics of diabetic ketoacidosis include acidosis, dehydration, and electrolyte imbalance.
Respirations are rapid (Kussmaul respirations), not slow, and flushing, not pallor, would occur.
DIF: Cognitive Level: Understanding REF: p. 1523
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
12. The nurse is preparing to admit a 7-year-old child with type 2 diabetes. What clinical features
of type 2 diabetes should the nurse recognize? (Select all that apply.)
a. Oral agents are effective.
b. Insulin is usually needed.
c. Ketoacidosis is infrequent.
d. Diet only is often effective.
e. Chronic complications frequently occur.
ANS: A, C, D
The clinical features of type 2 diabetes include the following: oral agents are effective,
ketoacidosis is infrequent, and diet only is often effective. Insulin is only needed in 20% to 30%
of cases and chronic complications occur infrequently.
DIF: Cognitive Level: Understanding REF: p. 1520
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. The nurse is planning to admit a 14-year-old adolescent with hyperparathyroidism. What
clinical manifestations should the nurse expect to observe in this patient? (Select all that apply.)
a. Polyuria
b. Diarrhea
c. Hypotension
d. Vague bone pain
e. Paresthesia in extremities
ANS: A, D, E
Clinical manifestations of hyperparathyroidism include polyuria, vague bone pain, and
paresthesia in the extremities. Constipation, not diarrhea, and hypertension, not hypotension, are
manifestations of hyperparathyroidism.
The Child with Cerebral Dysfunction
MULTIPLE CHOICE
1. An injury to which part of the brain will cause a coma?
a. Brainstem
b. Cerebrum
c. Cerebellum
d. Occipital lobe
ANS: A
Injury to the brainstem results in stupor and coma. Signs of damage to the cerebrum are specific
to the involved area. Individuals with frontal lobe injury may have impaired memory, personality
changes, or altered intellectual functioning. Individuals with damage to the cerebellum have
difficulties with coordination of muscle movements, including ataxia and nystagmus. Impaired
vision and functional blindness result from injury to the occipital lobe.
DIF: Cognitive Level: Understanding REF: p. 1425
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. What finding is a clinical manifestation of increased intracranial pressure (ICP) in children?
a. Low-pitched cry
b. Sunken fontanel
c. Diplopia, blurred vision
d. Increased blood pressure
ANS: C
Diplopia and blurred vision are signs of increased ICP in children. A high-pitched cry and a tense
or bulging fontanel are characteristic of increased ICP. Increased blood pressure, common in
adults, is rarely seen in children.
DIF: Cognitive Level: Analyzing REF: p. 1428
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on
relaxation called?
a. Twitching
b. Spasticity
c. Choreiform movements
d. Associated movements
ANS: C
Quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation are
called choreiform movements. Twitching is defined as spasmodic movements of short duration.
Spasticity is the prolonged and steady contraction of a muscle characterized by clonus
(alternating relaxation and contraction of the muscle) and exaggerated reflexes. Associated
movements are the voluntary movement of one muscle accompanied by the involuntary
movement of another muscle.
DIF: Cognitive Level: Understanding REF: p. 1430
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. What term is used when a patient remains in a deep sleep, responsive only to vigorous and
repeated stimulation?
a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative state
ANS: B
Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated
stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful)
stimuli. Obtundation describes a level of consciousness in which the child is arousable with
stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral
cortex.
DIF: Cognitive Level: Understanding REF: p. 1431
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. What term is used to describe a childs level of consciousness when the child is arousable with
stimulation?
a. Stupor
b. Confusion
c. Obtundation
d. Disorientation
ANS: C
Obtundation describes a level of consciousness in which the child is arousable with stimulation.
Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and
repeated stimulation. Confusion is impaired decision making. Disorientation is confusion
regarding time and place.
DIF: Cognitive Level: Understanding REF: p. 1431
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. The nurse is closely monitoring a child who is unconscious after a fall and notices that the
child suddenly has a fixed and dilated pupil. How should the nurse interpret this?
a. Eye trauma
b. Brain death
c. Severe brainstem damage
d. Neurosurgical emergency
ANS: D
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse
should immediately report this finding. Although a dilated pupil may be associated with eye
trauma, this child has experienced a neurologic insult. One fixed and dilated pupil is not
suggestive of brain death. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are
indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on
the same side of the brain.
DIF: Cognitive Level: Analyzing REF: p. 1433
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. The nurse is caring for a child with severe head trauma after a car accident. What is an
ominous sign that often precedes death?
a. Delirium
b. Papilledema
c. Flexion posturing
d. Periodic or irregular breathing
ANS: D
Periodic or irregular breathing is an ominous sign of brainstem (especially medullary)
dysfunction that often precedes complete apnea. Delirium is a state of mental confusion and
excitement marked by disorientation for time and place. Papilledema is edema and inflammation
of the optic nerve. It is commonly a sign of increased intracranial pressure. Flexion posturing is
seen with severe dysfunction of the cerebral cortex or of the corticospinal tracts above the
brainstem.
DIF: Cognitive Level: Applying REF: p. 1429
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. What test is never performed on a child who is awake?
a. Dolls head maneuver
b. Oculovestibular response
c. Assessment of pyramidal tract lesions
d. Funduscopic examination for papilledema
ANS: B
The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a
comatose child. The caloric test is painful and is never performed on an awake child or one who
has a ruptured tympanic membrane. The dolls head maneuver, assessment of pyramidal tract
lesions, and funduscopic examination for papilledema are not considered painful and can be
performed on awake children.
DIF: Cognitive Level: Analyzing REF: p. 1433 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
9. The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro,
tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings?
a. Neurologic health
b. Severe brain damage
c. Decorticate posturing
d. Decerebrate posturing
ANS: A
Moro, tonic neck, and withdrawal reflexes are three reflexes that are present in a healthy 2-
month-old infant and are expected in this age group.
DIF: Cognitive Level: Applying REF: p. 1434
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The nurse is preparing a school-age child for computed tomography (CT) scan to assess
cerebral function. The nurse should include what statement in preparing the child?
a. The scan will not hurt.
b. Pain medication will be given.
c. You will be able to move once the equipment is in place.
d. Unfortunately no one can remain in the room with you during the test.
ANS: A
For CT scans, the child must be immobilized. It is important to emphasize to the child that at no
time is the procedure painful. Pain medication is not required; however, sedation is sometimes
necessary. The child will not be allowed to move and will be immobilized. Someone is able to
remain with the child during the procedure.
DIF: Cognitive Level: Applying REF: p. 1435
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
11. What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in
an unconscious child?
a. Suction the child frequently.
b. Turn the childs head side to side every hour.
c. Provide environmental stimulation.
d. Avoid activities that cause pain or crying.
ANS: D
Unrelieved pain, crying, and emotional stress all contribute to increasing the ICP. Disturbing
procedures should be carried out at the same time as therapies that reduce ICP, such as sedation.
Suctioning is poorly tolerated by children. When necessary, it is preceded by hyperventilation
with 100% oxygen. Turning the head side to side is contraindicated for fear of compressing the
jugular vein. This would block the flow of blood from the brain, raising ICP. Nontherapeutic
touch and environmental stimulation increase ICP. Minimizing both touch and environmental
stimuli noise reduces ICP.
DIF: Cognitive Level: Applying REF: p. 1439
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
12. What nursing intervention is appropriate when caring for an unconscious child?
a. Avoid using narcotics or sedatives to provide comfort and pain relief.
b. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP).
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are contraindicated.
ANS: C
Often comatose patients cannot cope with the quantity of fluids that they normally tolerate.
Overhydration must be avoided to prevent fatal cerebral edema. Narcotics and sedatives should
be used as necessary to reduce pain and anxiety, which can increase ICP. The childs position
should be changed frequently to avoid complications such as pneumonia and skin breakdown.
Antipyretics are the method of choice for fever reduction.
DIF: Cognitive Level: Applying REF: p. 1439
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
13. What statement is descriptive of a concussion?
a. Petechial hemorrhages cause amnesia.
b. Visible bruising and tearing of cerebral tissue occur.
c. It is a transient and reversible neuronal dysfunction.
d. It is a slight lesion that develops remote from the site of trauma.
ANS: C
A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness
and responsiveness resulting from trauma to the head. Petechial hemorrhages on the superficial
aspects of the brain along the point of impact are a type of contusion but are not necessarily
associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue.
Contrecoup is a lesion that develops remote from the site of trauma as a result of an
accelerationdeceleration injury.
DIF: Cognitive Level: Understanding REF: p. 1444
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
14. What statement best describes a subdural hematoma?
a. Bleeding occurs between the dura and the skull.
b. Bleeding occurs between the dura and the cerebrum.
c. Bleeding is generally arterial, and brain compression occurs rapidly.
d. The hematoma commonly occurs in the parietotemporal region.
ANS: B
A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a
rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between
the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in
the parietotemporal region.
DIF: Cognitive Level: Understanding REF: p. 1446
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
15. A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse
immediately assesses airway, breathing, and circulation. What should be the next nursing action?
a. Place the child on his side.
b. Take the childs blood pressure.
c. Stabilize the childs neck and spine.
d. Check the childs scalp and back for bleeding.
ANS: C
After determining that the child is breathing and has adequate circulation, the next action is to
stabilize the neck and spine to prevent any additional trauma. The childs position should not be
changed until the neck and spine are stabilized. Blood pressure is a later assessment. A less
urgent but important assessment is inspection of the scalp for bleeding.
DIF: Cognitive Level: Applying REF: p. 1448
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
16. A school-age child has sustained a head injury and multiple fractures after being thrown from
a horse. The childs level of consciousness is variable. The parents tell the nurse that they think
their child is in pain because of periodic crying and restlessness. What is the most appropriate
nursing action?
a. Explain that analgesia is contraindicated with a head injury.
b. Have the parents describe the childs previous experiences with pain.
c. Consult with a practitioner about what analgesia can be safely administered.
d. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert.
ANS: C
A key nursing role is to provide sedation and analgesia for the child. Consultation with the
appropriate practitioner is necessary to avoid conflict between the necessity to monitor the childs
neurologic status and to promote comfort and relieve anxiety. Analgesia can be safely used in
individuals who have sustained head injuries. The childs previous experiences with pain should
be obtained as part of the assessment, but because of the severity of the injury, analgesia should
be provided as soon as possible. Analgesia can decrease anxiety and resultant increased
intracranial pressure.
DIF: Cognitive Level: Applying REF: p. 1450
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
17. The nurse is assessing a child who was just admitted to the hospital for observation after a
head injury. What clinical manifestation is the most essential part of the nursing assessment to
detect early signs of a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
ANS: D
The most important nursing observation is assessment of the childs level of consciousness.
Alterations in consciousness appear earlier in the progression of an injury than do alterations of
vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage.
DIF: Cognitive Level: Analyzing REF: p. 1451
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
18. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for
discharge, the nurse is discussing home care with her mother. What sign or symptom is
considered a manifestation of postconcussion syndrome and does not necessitate medical
attention?
a. Vomiting
b. Blurred vision
c. Behavioral changes
d. Temporary loss of consciousness
ANS: C
The parents are advised of probable posttraumatic symptoms that may be expected. These
include behavioral changes, sleep disturbances, emotional lability, and alterations in school
performance. If the child is vomiting, has blurred vision, or has temporary loss of consciousness,
she should be seen for evaluation.
DIF: Cognitive Level: Understanding REF: p. 1451
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
19. An 18-month-old child is brought to the emergency department after being found
unconscious in the family pool. What does the nurse identify as the primary problem in drowning
incidents?
a. Hypoxia
b. Aspiration
c. Hypothermia
d. Electrolyte imbalance
ANS: A
Hypoxia is the primary problem because it results in global cell damage, with different cells
tolerating variable lengths of anoxia. Neurons sustain irreversible damage after 4 to 6 minutes of
submersion. Severe neurologic damage occurs from hypoxia in 3 to 6 minutes. Aspiration of
fluid does occur, resulting in pulmonary edema, atelectasis, airway spasm, and pneumonitis,
which complicate the anoxia. Hypothermia occurs rapidly, except in hot tubs. Electrolyte
imbalances do result, but they are not a major cause of morbidity and mortality.
DIF: Cognitive Level: Understanding REF: p. 1453
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
20. The mother of a 1-month-old infant tells the nurse she worries that her baby will get
meningitis like the childs younger brother had when he was an infant. The nurse should base a
response on which information?
a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.
d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.
ANS: D
H. influenzae type B meningitis has been virtually eradicated in areas of the world where the
vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is
significant because of the residual damage caused by undiagnosed and untreated or inadequately
treated cases. The leading causes of neonatal meningitis are the group B streptococci
and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections.
No genetic predisposition exists. Vaccinations are not available for all of the potential causative
organisms.
DIF: Cognitive Level: Applying REF: p. 1454
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
21. A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial
orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows
that antibiotic therapy will begin when?
a. After the diagnosis is confirmed
b. When the medication is received from the pharmacy
c. After the childs fluid and electrolyte balance is stabilized
d. As soon as the practitioner is notified of the culture results
ANS: B
Antimicrobial therapy is begun as soon as a presumptive diagnosis is made. The choice of drug is
based on the most likely infective agent. Drug choice may be adjusted when the culture results
are obtained. Waiting for culture results to begin therapy increases the risk of neurologic damage.
Although fluid and electrolyte balance is important, there is no indication that this child is
unstable. Antibiotic therapy would be a priority intervention.
DIF: Cognitive Level: Analyzing REF: p. 1454
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. The nurse is planning care for a school-age child with bacterial meningitis. What intervention
should be included?
a. Keep environmental stimuli to a minimum.
b. Have the child move her head from side to side at least every 2 hours.
c. Avoid giving pain medications that could dull sensorium.
d. Measure head circumference to assess developing complications.
ANS: A
The room is kept as quiet as possible and environmental stimuli are kept to a minimum. Most
children with meningitis are sensitive to noise, bright lights, and other external stimuli. The
nuchal rigidity associated with meningitis would make moving the head from side to side a
painful intervention. If pain is present, the child should be treated appropriately. Failure to treat
can cause increased intracranial pressure. In this age group, the head circumference does not
change. Signs of increased intracranial pressure would need to be assessed.
DIF: Cognitive Level: Applying REF: p. 1458 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
23. A young childs parents call the nurse after their child is bitten by a raccoon in the woods. The
nurses recommendation should be based on what knowledge?
a. Antirabies prophylaxis must be initiated immediately.
b. The child should be hospitalized for close observation.
c. No treatment is necessary if thorough wound cleaning is done.
d. Antirabies prophylaxis must be initiated as soon as clinical manifestations appear.
ANS: A
Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive
immunization with human rabies immunoglobulin (HRIG) as soon as possible. Hospitalization is
not necessary. The wound cleansing, passive immunization, and immunoglobulin administration
can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine.
DIF: Cognitive Level: Applying REF: p. 1462
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
24. What intervention should be beneficial in reducing the risk of Reye syndrome?
a. Immunization against the disease
b. Medical attention for all head injuries
c. Prompt treatment of bacterial meningitis
d. Avoidance of aspirin for children with varicella or those suspected of having influenza
ANS: D
Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness,
either varicella or influenza. A potential association exists between aspirin therapy and the
development of Reye syndrome, so use of aspirin is avoided. No immunization currently exists
for Reye syndrome. Reye syndrome is not correlated with head injuries or bacterial meningitis.
DIF: Cognitive Level: Understanding REF: p. 1463 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
25. What term refers to seizures that involve both hemispheres of the brain?
a. Absence
b. Acquired
c. Generalized
d. Complex partial
ANS: C
Clinical observations of generalized seizures indicate that the initial involvement is from both
hemispheres. Absence seizures have a sudden onset and are characterized by a brief loss of
consciousness, a blank stare, and automatisms. Acquired seizure disorder is a result of a brain
injury from a variety of factors; it is not a term that labels the type of seizure. Complex partial
seizures are the most common seizures. They may begin with an aura and be manifested as
repetitive involuntary activities without purpose, carried out in a dreamy state.
DIF: Cognitive Level: Understanding REF: p. 1465
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
26. What is the initial clinical manifestation of generalized seizures?
a. Confusion
b. Feeling frightened
c. Loss of consciousness
d. Seeing flashing lights
ANS: C
Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical
manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical
manifestations of a complex partial seizure.
DIF: Cognitive Level: Understanding REF: p. 1466
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
27. What type of seizure may be difficult to detect?
a. Absence
b. Generalized
c. Simple partial
d. Complex partial
ANS: A
Absence seizures may go unrecognized because little change occurs in the childs behavior during
the seizure. Generalized, simple partial, and complex partial all have clinical manifestations that
are observable.
DIF: Cognitive Level: Understanding REF: p. 1468
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
28. What is important to incorporate in the plan of care for a child who is experiencing a seizure?
a. Describe and record the seizure activity observed.
b. Suction the child during a seizure to prevent aspiration.
c. Place a tongue blade between the teeth if they become clenched.
d. Restrain the child when seizures occur to prevent bodily harm.
ANS: A
When a child is having a seizure, the priority nursing care is observation of the child and seizure.
The nurse then describes and records the seizure activity. The child is not suctioned during the
seizure. If possible, the child should be placed on the side, facilitating drainage to prevent
aspiration.
DIF: Cognitive Level: Applying REF: p. 1437
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
29. A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure
at school that lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion
occurs. What is the most appropriate initial action by the school nurse?
a. Stay with child and have someone else call emergency medical services (EMS).
b. Notify the parent and regular practitioner.
c. Notify the parent that the child should go home.
d. Stay with the child, offering calm reassurance.
ANS: A
Because this is the childs first seizure and it lasted more than 5 minutes, EMS should be called to
transport the child, and evaluation should be performed as soon as possible. The nurse should
stay with the recovering child while someone else notifies EMS.
DIF: Cognitive Level: Applying REF: p. 1478
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
30. A child has been seizure free for 2 years. A father asks the nurse how much longer the child
will need to take the antiseizure medications. How should the nurse respond?
a. Medications can be discontinued at this time.
b. The child will need to take the drugs for 5 years after the last seizure.
c. A step-wise approach will be used to reduce the dosage gradually.
d. Seizure disorders are a lifelong problem. Medications cannot be discontinued.
ANS: C
A predesigned protocol is used to wean a child gradually off antiseizure medications, usually
when the child is seizure free for 2 years. Medications must be gradually reduced to minimize
the recurrence of seizures. The risk of recurrence is greatest within 6 months after
discontinuation.
DIF: Cognitive Level: Applying REF: p. 1478
TOP: Nursing Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
31. A young adolescent experiences infrequent migraine episodes. What pharmacologic
intervention is most likely to be prescribed?
a. Opioid
b. Lorazepam
c. Ergotamine
d. Sumatriptan
ANS: D
Sumatriptan is a serotonin agonist at specific vascular serotonin receptor sites and causes
vasoconstriction in large intracranial arteries. Opioids are used infrequently because they rarely
work on the mechanism of pain. Lorazepam is a benzodiazepine that acts as an anxiolytic and
sedative. It is not indicated for treatment of migraine episodes. Ergotamine, an a-adrenergic
blocker, is used for adult vascular headaches, but it is not used in adolescents because of the side
effects.
DIF: Cognitive Level: Understanding REF: p. 1483
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
32. The nurse is teaching the parents of a 3-year-old child who has been diagnosed with tonic-
clonic seizures. What statement by the parent should indicate a correct understanding of the
teaching?
a. I should attempt to restrain my child during a seizure.
b. My child will need to avoid contact sports until adulthood.
c. I should place a pillow under my childs head during a seizure.
d. My child will need to be taken to the emergency department [ED] after each seizure.
ANS: C
Parents should try to place a pillow or folded blanket under the childs head for protection. The
parent should not try to restrain the child during the seizure. The child does not need to go to the
ED with each seizures; the nurse can teach parents certain criteria for when their child would
need to be seen. Discussing what will happen in adulthood is not appropriate at this time.
DIF: Cognitive Level: Analyzing REF: p. 1468
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
33. The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric
Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include
in the childs care plan?
a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.
b. Maintain an active, stimulating environment.
c. Perform chest percussion and suctioning every 1 to 2 hours.
d. Perform active range of motion and nontherapeutic touch every 8 hours.
ANS: A
Nursing activities for children with head trauma and increased intracranial pressure (ICP) include
elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position.
The nurse should try to maintain a quiet, nonstimulating environment for a child with increased
ICP. Chest percussion and suctioning should be performed judiciously because they can elevate
ICP. Range of motion should be passive and nontherapeutic touch should be avoided because
both of these activities can increase ICP.
DIF: Cognitive Level: Applying REF: p. 1439
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
34. What clinical manifestations suggest hydrocephalus in an infant?
a. Closed fontanel and high-pitched cry
b. Bulging fontanel and dilated scalp veins
c. Constant low-pitched cry and restlessness
d. Depressed fontanel and decreased blood pressure
ANS: B
Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of
hydrocephalus in neonates. A closed fontanel, high-pitched cry, constant low-pitched cry,
restlessness, a depressed fontanel, and decreased blood pressure are not clinical manifestations of
hydrocephalus, but all should be referred for evaluation.
DIF: Cognitive Level: Understanding REF: p. 1482
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
35. A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurses response
should be based on which knowledge?
a. It can be diagnosed only after birth.
b. It can be diagnosed by chromosome studies.
c. It can be diagnosed with fetal ultrasonography.
d. It can be diagnosed by measuring the lecithin-to-sphingomyelin ratio.
ANS: C
Hydrocephalus can be diagnosed by fetal ultrasonography as early as 14 weeks of gestation.
Most incidents of hydrocephalus are not chromosomal in origin. The lecithin-to-sphingomyelin
ratio can be used to determine fetal lung maturity.
DIF: Cognitive Level: Analyzing REF: p. 1486
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
36. A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating
hydrocephalus. What is a common reason for elective revision of this shunt?
a. Meningitis
b. Gastrointestinal upset
c. Hydrocephalus resolution
d. Growth of the child since the initial shunting
ANS: D
An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate
the childs growth. Meningitis would require an emergent replacement or revision of the shunt.
Gastrointestinal upset alone would not indicate the need for shunt revision. Noncommunicating
hydrocephalus will not resolve without surgical intervention.
DIF: Cognitive Level: Understanding REF: p. 1487 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
37. What is a priority of care when a child has an external ventricular drain (EVD)?
a. Irrigation of drain to maintain flow
b. As-needed dressing changes if dressing becomes wet
c. Frequent assessment of amount and color of drainage
d. Maintaining the EVD below the level of the childs head
ANS: C
The EVD is inserted into the childs ventricle. Frequent assessment is necessary to determine
amount of drainage and whether an infection is present. The EVD is a closed system and is not
opened for irrigation. Antibiotics may be administered through the drain, but this is usually done
by the neuropractitioner. The dressing is not changed. If it becomes wet, then the practitioner
should be notified that cerebrospinal fluid (CSF) may be leaking. Unless ordered, maintaining
the EVD below the level of the childs head position will create too much pressure and potentially
drain too much CSF.
DIF: Cognitive Level: Understanding REF: p. 1438 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
38. The nurse is discussing long-term care with the parents of a child who has a
ventriculoperitoneal shunt. What issues should be addressed?
a. Most childhood activities must be restricted.
b. Cognitive impairment is to be expected with hydrocephalus.
c. Wearing head protection is essential until the child reaches adulthood.
d. Shunt malfunction or infection requires immediate treatment.
ANS: D
Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be
assessed and treated immediately. Limits should be appropriate to the childs developmental age.
Except for contact sports, the child will have few restrictions. Cognitive impairment depends on
the extent of damage before the shunt was placed.
DIF: Cognitive Level: Applying REF: p. 1487
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
39. A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for
noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a
revision is necessary?
a. Tachycardia
b. Gastrointestinal upset
c. Hypotension
d. Alteration in level of consciousness
ANS: D
In older children, who are usually admitted to the hospital for elective or emergency shunt
revision, the most valuable indicators of increasing intracranial pressure are an alteration in the
childs level of consciousness, complaint of headache, and changes in interaction with the
environment.
DIF: Cognitive Level: Analyzing REF: p. 1489
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
40. After a tonic-clonic seizure, what symptoms should the nurse expect the child to experience?
a. Diarrhea and abdominal discomfort
b. Irritability and hunger
c. Lethargy and confusion
d. Nervousness and excitability
ANS: C
In the postictal phase, after a tonic-clonic seizure, the child may remain semiconscious and
difficult to arouse. The average duration of the postictal phase is usually 30 minutes. The child
may remain confused or sleep for several hours. He or she may have mild impairment of fine
motor movements. The child may have visual and speech difficulties and may vomit or complain
of headache.
DIF: Cognitive Level: Analyzing REF: p. 1467
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
41. What is the antiepileptic medication that requires monitoring of vitamin D and folic acid?
a. Topiramate (Topamax)
b. Valproic acid (Depakene)
c. Gabapentin (Neurontin)
d. Phenobarbital (Luminal)
ANS: D
Children taking phenobarbital or phenytoin should receive adequate vitamin D and folic acid
because deficiencies of both have been associated with these drugs.
DIF: Cognitive Level: Analyzing REF: p. 1479
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
42. A 2-year-old child starts to have a tonic-clonic seizure. The childs jaws are clamped. What is
the most important nursing action at this time?
a. Place a padded tongue blade between the childs jaws.
b. Stay with the child and observe his respiratory status.
c. Prepare the suction equipment.
d. Restrain the child to prevent injury.
ANS: B
It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The
nurse must remain calm, stay with the child, and prevent the child from sustaining any harm
during the seizure. The nurse should not move or forcefully restrain the child during a tonic-
clonic seizure and should not place a solid object between the teeth. Suctioning may be needed
but not until the seizure has ended.
DIF: Cognitive Level: Applying REF: p. 1478
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
43. A child has been admitted with status epilepticus. An emergency medication has been
ordered. What medication should the nurse expect to be prescribed?
a. Lorazepam (Ativan)
b. Phenytoin (Dilantin)
c. Topiramate (Topamax)
d. Ethosuximide (Zarontin)
ANS: A
For in-hospital management of status epilepticus, intravenous diazepam or lorazepam (Ativan) is
the first-line drug of choice. Lorazepam is the preferred agent because of its rapid onset (25
minutes) and long half-life (1224 hours) with few side effects.
DIF: Cognitive Level: Analyzing REF: p. 1473 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
44. A child is on phenytoin (Dilantin). What should the nurse encourage?
a. Fluid restriction
b. Good dental hygiene
c. A decrease in vitamin D intake
d. Taking the medication with milk
ANS: B
Chronic treatment with phenytoin may cause gum hypertrophy. Children taking phenobarbital or
phenytoin should receive adequate vitamin D and folic acid because deficiencies of both have
been associated with these drugs. The medication should not be taken with milk, and fluids
should be encouraged, not restricted.
DIF: Cognitive Level: Applying REF: p. 1472
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
45. A child has a seizure disorder. What test should be done to gather the most specific
information about the type of seizure the child is having?
a. Sleep study
b. Skull radiography
c. Serum electrolytes
d. Electroencephalogram (EEG)
ANS: D
An EEG is obtained for all children with seizures and is the most useful tool for evaluating a
seizure disorder. The EEG confirms the presence of abnormal electrical discharges and provides
information on the seizure type and the focus. The EEG is carried out under varying
conditionswith the child asleep, awake, awake with provocative stimulation (flashing lights,
noise), and hyperventilating. Stimulation may elicit abnormal electrical activity, which is
recorded on the EEG. Various seizure types produce characteristic EEG patterns: high-voltage
spike discharges are seen in tonic-clonic seizures, with abnormal patterns in the intervals
between seizures; a three-per-second spike and wave pattern is observed in an absence seizure;
and absence of electrical activity in an area suggests a large lesion, such as an abscess or
subdural collection of fluid.
DIF: Cognitive Level: Analyzing REF: p. 1470
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
46. A child develops syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a
complication to meningitis. What action should be verified before implementing?
a. Forcing fluids
b. Daily weights with strict input and output (I and O)
c. Strict monitoring of urine volume and specific gravity
d. Close observation for signs of increasing cerebral edema
ANS: A
The treatment of SIADH consists of fluid restriction until serum electrolytes and osmolality
return to normal levels. SIADH often occurs in children who have meningitis. Monitoring
weights, keeping I and O and specific gravity of urine, and observing for signs of increasing
cerebral edema are all part of the nursing care for a child with SIADH.
DIF: Cognitive Level: Applying REF: p. 1440
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
47. When taking the history of a child hospitalized with Reye syndrome, the nurse should not be
surprised if a week ago the child had recovered from what?
a. Measles
b. Influenza
c. Meningitis
d. Hepatitis
ANS: B
The etiology of Reye syndrome is not well understood, but most cases follow a common viral
illness, typically influenza or varicella.
DIF: Cognitive Level: Analyzing REF: p. 1462
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
48. If an intramuscular (IM) injection is administered to a child who has Reye syndrome, the
nurse should monitor for what?
a. Bleeding
b. Infection
c. Poor absorption
d. Itching at the injection site
ANS: A
The nurse should watch for bleeding from the site. Because of related liver dysfunction with
Reye syndrome, laboratory studies, such as prolonged bleeding time, should be monitored to
determine impaired coagulation.
DIF: Cognitive Level: Applying REF: p. 1463
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
49. A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is
lethargic and very irritable with a temperature of 102 F. What should the nurses care plan
include?
a. Observing the childs voluntary movement
b. Checking the Babinski reflex every 4 hours
c. Checking the Brudzinski reflex every 1 hour
d. Assessing the level of consciousness (LOC) and vital signs every 2 hours
ANS: D
Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is
carried out at frequent intervals on a child with meningitis. The nurse should avoid actions that
cause pain or increase discomfort, such as lifting the childs head, so the Brudzinski reflex should
not be checked hourly. Checking the Babinski reflex or childs voluntary movements will not help
with assessing the childs status.
DIF: Cognitive Level: Applying REF: p. 1459
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
50. A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse
expects which results for the cerebrospinal fluid that can confirm the diagnosis of meningitis?
a. WBCs; glucose
b. RBCs; normal WBCs
c. glucose; normal RBCs
d. Normal RBCs; normal glucose
ANS: A
A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured and samples
are obtained for culture, Gram stain, blood cell count, and determination of glucose and protein
content. The findings are usually diagnostic. The patient generally has an elevated white blood
cell count, often predominantly polymorphonuclear leukocytes. The glucose level is reduced,
generally in proportion to the duration and severity of the infection.
DIF: Cognitive Level: Analyzing REF: p. 1457
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure
(ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all
that apply.)
a. High-pitched cry
b. Poor feeding
c. Setting-sun sign
d. Sunken fontanel
e. Distended scalp veins
f. Decreased head circumference
ANS: A, B, C, E
Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding,
setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and
an increased head circumference.
DIF: Cognitive Level: Applying REF: p. 1428
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. The nurse is caring for a child with increased intracranial pressure (ICP). What interventions
should the nurse plan for this child?(Select all that apply.)
a. Avoid jarring the bed.
b. Keep the room brightly lit.
c. Keep the bed in a flat position.
d. Administer prescribed stool softeners.
e. Administer a prescribed antiemetic for nausea.
ANS: A, D, E
Other measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit
environment; limiting visitors; preventing any sudden, jarring movement, such as banging into
the bed; and preventing an increase in ICP. The latter is most effectively achieved by proper
positioning and prevention of straining, such as during coughing, vomiting, or defecating. An
antiemetic should be administered to prevent vomiting, and stool softeners should be prescribed
to prevent straining with bowel movements. The head of the bed should be elevated 15 to 30
degrees.
DIF: Cognitive Level: Applying REF: p. 1438 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
3. The nurse is preparing to admit a 5-year-old with an epidural hemorrhage. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Headache
b. Vomiting
c. Irritability
d. Cephalhematoma
e. Pallor with anemia
ANS: A, B, C
The classic clinical picture of an epidural hemorrhage is a lucid interval (momentary
unconsciousness) followed by a normal period for several hours, and then lethargy or coma due
to blood accumulation in the epidural space and compression of the brain. The child may be seen
with varying degrees of impaired consciousness depending on the severity of the traumatic
injury. Common symptoms in a child with no neurologic deficit are irritability, headache, and
vomiting. In infants younger than 1 year of age, the most common symptoms are irritability,
pallor with anemia, and cephalhematoma.
DIF: Cognitive Level: Applying REF: p. 1446
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. The nurse is caring for a child with a subdural hematoma. The nurse should assess for what
signs that can indicate brainstem compression? (Select all that apply.)
a. Coma
b. Lethargy
c. Hemiplegia
d. Hemiparesis
e. Unequal pupils
ANS: C, D, E
Hemiparesis, hemiplegia, and anisocoria (unequal pupils) are signs of brainstem compression
and require emergency treatment targeted at decreasing increased intracranial pressure. Coma
and lethargy are seen with a subdural hematoma but do not indicate a brainstem compression.
DIF: Cognitive Level: Analyzing REF: p. 1447
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. The nurse is preparing to admit a neonate with bacterial meningitis. What clinical
manifestations should the nurse expect to observe?(Select all that apply.)
a. Jaundice
b. Cyanosis
c. Poor tone
d. Nuchal rigidity
e. Poor sucking ability
ANS: A, B, C, E
Clinical manifestations of bacterial meningitis in a neonate include jaundice, cyanosis, poor tone,
and poor sucking ability. The neck is usually supple in neonates with meningitis, and there is no
nuchal rigidity.
DIF: Cognitive Level: Applying REF: p. 1456
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. The nurse is preparing to admit an adolescent with bacterial meningitis. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Fever
b. Chills
c. Headache
d. Poor tone
e. Drowsiness
ANS: A, B, C, E
Clinical manifestations of bacterial meningitis in an adolescent include, fever, chills, headache,
and drowsiness. Hyperactivity is present, not poor tone.
DIF: Cognitive Level: Applying REF: p. 1456
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. The nurse is caring for a child with meningitis. What acute complications of meningitis should
the nurse continuously assess the child for? (Select all that apply.)
a. Seizures
b. Cerebral palsy
c. Cerebral edema
d. Hydrocephalus
e. Cognitive impairments
ANS: A, C, E
Acute complications of meningitis include syndrome of inappropriate antidiuretic hormone
(SIADH), subdural effusions, seizures, cerebral edema and herniation, and hydrocephalus. Long-
term complications include cerebral palsy, cognitive impairments, learning disorder, attention
deficit hyperactivity disorder, and seizures.
DIF: Cognitive Level: Applying REF: p. 1440
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. What cerebrospinal fluid (CSF) analysis should the nurse expect with viral meningitis? (Select
all that apply.)
a. Color is turbid.
b. Protein count is normal.
c. Glucose is decreased.
d. Gram stain findings are negative.
e. White blood cell (WBC) count is slightly elevated.
ANS: B, D, E
The CSF analysis in viral meningitis shows a normal or slightly elevated protein count, negative
Gram stain, and a slightly elevated WBC. The color is clear or slightly cloudy, and the glucose
level is normal.
DIF: Cognitive Level: Applying REF: p. 1460
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. The nurse is preparing to admit an adolescent with encephalitis. What clinical manifestations
should the nurse expect to observe?(Select all that apply.)
a. Malaise
b. Apathy
c. Lethargy
d. Hypoactivity
e. Hypothermia
ANS: A, B, D
The clinical manifestations of encephalitis include malaise, apathy, and lethargy. There is
hyperactivity, not hypoactivity, and hyperthermia, not hypothermia.
DIF: Cognitive Level: Applying REF: p. 1461
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The nurse is preparing to admit a 7-year-old child with complex partial seizures. What
clinical features of complex partial seizures should the nurse recognize? (Select all that apply.)
a. They last less than 10 seconds.
b. There is usually no aura.
c. Mental disorientation is common.
d. There is frequently a postictal state.
e. There is usually an impaired consciousness.
ANS: C, D, E
Clinical features of complex partial seizures include the following: it is common to have mental
disorientation, there is frequently a postictal state, and there is usually an impaired
consciousness. These seizures last longer than 10 seconds (usually longer than 60 seconds), and
there is usually an aura.
DIF: Cognitive Level: Analyzing REF: p. 1466
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. What effects of an altered pituitary secretion in a child with meningitis indicates syndrome of
inappropriate antidiuretic hormone (SIADH)? (Select all that apply.)
a. Hypotension
b. Serum sodium is decreased
c. Urinary output is decreased
d. Evidence of overhydration
e. Urine specific gravity is increased
ANS: B, C, D, E
The serum sodium is decreased, urinary output is decreased, evidence of overhydration is
present, and urine specific gravity is increased in SIADH. Hypertension, not hypotension,
occurs.
DIF: Cognitive Level: Analyzing REF: p. 1440
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
12. The nurse is caring for a child with an epidural hematoma. The nurse should assess for what
signs that can indicate Cushing triad?(Select all that apply.)
a. Fever
b. Flushing
c. Bradycardia
d. Systemic hypertension
e. Respiratory depression
ANS: C, D, E
Cushing triad (systemic hypertension, bradycardia, and respiratory depression) is a late sign of
impending brainstem herniation. Fever or flushing does not occur with Cushing triad.
DIF: Cognitive Level: Applying REF: p. 1446
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. The nurse is preparing to admit a 10-year-old child with absence seizures. What clinical
features of absence seizures should the nurse recognize? (Select all that apply.)
a. There is no aura.
b. There is a postictal state.
c. They usually last longer than 30 seconds.
d. There is a brief loss of consciousness.
e. There is an occasional clonic movement.
ANS: A, D, E
Clinical features of absence seizures include no auras, a brief loss of consciousness, and an
occasional clonic movement. There is no postictal state, and the seizures rarely last longer than
30 seconds.
DIF: Cognitive Level: Understanding REF: p. 1466
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
14. The nurse is teaching the parents of a child with a seizure disorder about the triggers that can
cause a seizure. What should the nurse include in the teaching session? (Select all that apply.)
a. Cold
b. Sugared drinks
c. Emotional stress
d. Flickering lights
e. Hyperventilation
ANS: C, D, E
The most common factors that may trigger seizures in children include emotional stress, sleep
deprivation, fatigue, fever, and physical exercise. Other precipitating factors include sleep,
flickering lights, menstrual cycle, alcohol, heat, hyperventilation, and fasting. Cold and sugared
drinks are not triggers for seizures.
The Child with Cognitive, Sensory, or Communication Impairment
MULTIPLE CHOICE
1. The American Association on Intellectual and Developmental Disabilities (AAIDD), formerly
the American Association on Cognitive Impairment, classifies cognitive impairment based on
what parameter?
a. Age of onset
b. Subaverage intelligence
c. Adaptive skill domains
d. Causative factors for cognitive impairment
ANS: C
The AAIDD has categorized cognitive impairment into adaptive skill domains. The child must
demonstrate functional impairment in at least two of the following adaptive skill domains:
communication, self-care, home living, social skills, use of community resources, self-direction,
health and safety, functional academics, leisure, and work. Age of onset before 18 years is part of
the former criteria. Low intelligence quotient (IQ) alone is not the sole criterion for cognitive
impairment. Etiology is not part of the classification.
DIF: Cognitive Level: Understanding REF: p. 824
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
2. Secondary prevention for cognitive impairment includes what activity?
a. Genetic counseling
b. Avoidance of prenatal rubella infection
c. Preschool education and counseling services
d. Newborn screening for treatable inborn errors of metabolism
ANS: D
Secondary prevention involves activities that are designed to identify the condition early and
initiate treatment to avert cerebral damage. Inborn errors of metabolism such as hypothyroidism,
phenylketonuria, and galactosemia can cause cognitive impairment. Genetic counseling and
avoidance of prenatal rubella infections are examples of primary prevention strategies to
preclude the occurrence of disorders that can cause cognitive impairment. Preschool education
and counseling services are examples of tertiary prevention. These are designed to include early
identification of conditions and provision of appropriate therapies and rehabilitation services.
DIF: Cognitive Level: Understanding REF: p. 826
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
3. What is a primary goal in caring for a child with cognitive impairment?
a. Developing vocational skills
b. Promoting optimum development
c. Finding appropriate out-of-home care
d. Helping child and family adjust to future care
ANS: B
The goal for children with cognitive impairment is the promotion of optimum social, physical,
cognitive, and adaptive development as individuals within a family and community. Vocational
skills are only one part of that goal. The focus must also be on the family and other aspects of
development. Out-of-home care is considered part of the childs development. Optimum
development includes adjustment for both the family and child.
DIF: Cognitive Level: Understanding REF: p. 828 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
4. One of the techniques that has been especially useful for learners having cognitive impairment
is called fading. What description best explains this technique?
a. Positive reinforcement when tasks or behaviors are mastered
b. Repeated verbal explanations until tasks are faded into the childs development
c. Negative reinforcement for specific tasks or behaviors that need to be faded out
d. Gradually reduces the assistance given to the child so the child becomes more independent
ANS: D
Fading is physically taking the child through each sequence of the desired activity and gradually
fading out the physical assistance so the child becomes more independent. Positive
reinforcement when tasks or behaviors are mastered is part of behavior modification. An
essential component is ignoring undesirable behaviors. Verbal explanations are not as effective as
demonstration and physical guidance. Consistent negative reinforcement is helpful, but positive
reinforcement that focuses on skill attainment should be incorporated.
DIF: Cognitive Level: Analyzing REF: p. 827 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
5. The parents of a child with cognitive impairment ask the nurse for guidance with discipline.
What should the nurses recommendation be based on?
a. Discipline is ineffective with cognitively impaired children.
b. Cognitively impaired children do not require discipline.
c. Behavior modification is an excellent form of discipline.
d. Physical punishment is the most appropriate form of discipline.
ANS: C
Discipline must begin early. Limit-setting measures must be clear, simple, consistent, and
appropriate for the childs mental age. Behavior modification, especially reinforcement of desired
behavior and use of time-out procedures, is an appropriate form of behavior control. Aversive
strategies should be avoided in disciplining the child.
DIF: Cognitive Level: Applying REF: p. 827
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
6. What intervention is most appropriate to facilitate social development of a child with a
cognitive impairment?
a. Provide age-appropriate toys and play activities.
b. Avoid exposure to strangers who may not understand cognitive development.
c. Provide peer experiences, such as infant stimulation and preschool programs.
d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.
ANS: C
The acquisition of social skills is a complex task. Initially, an infant stimulation program should
be used. Children of all ages need peer relationships. Parents should enroll the child in preschool.
When older, they should have peer experiences similar to those of other children such as group
outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play
activities is important, but peer interactions facilitate social development. Parents should expose
the child to individuals who do not know the child. This enables the child to practice social skills.
Verbal skills are delayed more often than physical skills.
DIF: Cognitive Level: Applying REF: p. 835
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
7. The nurse is discussing sexuality with the parents of an adolescent girl who has a moderate
cognitive impairment. What factor should the nurse consider when dealing with this issue?
a. Sterilization is recommended for any adolescent with cognitive impairment.
b. Sexual drive and interest are very limited in individuals with cognitive impairment.
c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct.
d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.
ANS: C
Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A
well-defined, concrete code of conduct with specific instructions for handling certain situations
should be defined for the adolescent. Permanent contraception by sterilization presents moral and
ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some
states. The adolescent needs to have practical sexual information regarding physical development
and contraception. Cognitively impaired individuals may desire to marry and have families. The
adolescent needs to be protected from individuals who may make intimate advances.
DIF: Cognitive Level: Applying REF: p. 829
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
8. The mother of a young child with cognitive impairment asks for suggestions about how to
teach her child to use a spoon for eating. The nurse should make which recommendation?
a. Do a task analysis first.
b. Do not expect this task to be learned.
c. Continue to spoon feed the child until the child tries to do it alone.
d. Offer only finger foods so spoon feeding is unnecessary.
ANS: A
Successful teaching begins with a task analysis. The endpoint (self-feeding, toilet training, and so
on) is broken down into the component steps. The child is then guided to master the individual
steps in sequence. Depending on the childs functional level, using a spoon for eating should be
an achievable goal. The child requires demonstration and then guided training for each
component of the self-feeding. Feeding finger foods so spoon feeding is unnecessary eliminates
some of the intermediate steps that are necessary to using a fork and spoon. For socialization
purposes, it is desirable that a child use feeding implements.
DIF: Cognitive Level: Understanding REF: p. 827
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
9. A newborn assessment shows a separated sagittal suture, oblique palpebral fissures, a
depressed nasal bridge, a protruding tongue, and transverse palmar creases. These findings are
most suggestive of which condition?
a. Microcephaly
b. Cerebral palsy
c. Down syndrome
d. Fragile X syndrome
ANS: C
These are characteristics associated with Down syndrome. An infant with microcephaly has a
small head. Cerebral palsy is a diagnosis not usually made at birth; no characteristic physical
signs are present. The infant with fragile X syndrome has increased head circumference; long,
wide, or protruding ears; a long, narrow face with a prominent jaw; hypotonia; and a high-arched
palate.
DIF: Cognitive Level: Understanding REF: p. 834
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the
nurse that he is difficult to hold, that hes like a rag doll. He doesnt cuddle up to me like my other
babies did. What is the nurses best interpretation of this lack of clinging or molding?
a. Sign of detachment and rejection
b. Indicative of maternal deprivation
c. A physical characteristic of Down syndrome
d. Suggestive of autism associated with Down syndrome
ANS: C
Infants with Down syndrome have hypotonicity of muscles and hyperextensibility of joints,
which complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll.
Holding the infant is difficult and cumbersome, and parents may feel that they are inadequate. A
lack of clinging or molding is characteristic of Down syndrome, not detachment. There is no
evidence of maternal deprivation. Autism is not associated with Down syndrome, and it would
not be evident at 2 weeks of age.
DIF: Cognitive Level: Analyzing REF: p. 836
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. Many of the clinical features of Down syndrome present challenges to caregivers. Based on
these features, what intervention should be included in the childs care?
a. Delay feeding solid foods until the tongue thrust has stopped.
b. Modify the diet as necessary to minimize the diarrhea that often occurs.
c. Provide calories appropriate to the childs mental age.
d. Use a cool-mist vaporizer to keep the mucous membranes moist and secretions liquefied.
ANS: D
The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and
increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep
the mucous membranes moist and liquefy secretions. Respiratory tract infections combined with
cardiac anomalies are the primary cause of death in the first years. The child has a protruding
tongue, which makes feeding difficult. The parents must persist with feeding while the child
continues the physiologic response of the tongue thrust. The child is predisposed to constipation.
Calories should be appropriate to the childs weight and growth needs, not mental age.
DIF: Cognitive Level: Applying REF: p. 837 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
12. What description applies to fragile X syndrome?
a. Chromosomal defect affecting only females
b. Second most common genetic cause of cognitive impairment
c. Most common cause of uninherited cognitive impairment
d. Chromosomal defect that follows the pattern of X-linked recessive disorders
ANS: B
Fragile X syndrome is the most common inherited cause of cognitive impairment and the second
most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily
affects males and follows the pattern of X-linked dominant inheritance with reduced penetrance.
DIF: Cognitive Level: Understanding REF: p. 837
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. The nurse should suspect a hearing impairment in an infant who fails to demonstrate which
behavior?
a. Babbling by age 12 months
b. Eye contact when being spoken to
c. Startle or blink reflex to sound
d. Gesturing to indicate wants after age 15 months
ANS: A
The absence of babbling or inflections in voice by at least age 7 months is an indication of
hearing difficulties. Lack of eye contact is not indicative of a hearing loss. An infant with a
hearing impairment might react to a loud noise but not respond to the spoken word. The child
with hearing impairment uses gestures rather than vocalizations to express desires at this age.
DIF: Cognitive Level: Understanding REF: p. 854
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
14. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing
aid is making an annoying whistling sound that the child cannot hear. What intervention is the
most appropriate nursing action?
a. Ignore the sound.
b. Suggest he reinsert the hearing aid.
c. Ask him to reverse the hearing aids in his ears.
d. Suggest he raise the volume of the hearing aid.
ANS: B
The whistling sound is acoustic feedback. The nurse should have the child remove the hearing
aid and reinsert it, making sure no hair is caught between the ear mold and the ear canal.
Ignoring the sound or suggesting he raise the volume of the hearing aid would be annoying to
others. The hearing aids are molded specifically for each ear.
DIF: Cognitive Level: Applying REF: p. 842
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
15. What technique facilitates lip reading by a hearing-impaired child?
a. Speak at an even rate.
b. Avoid using facial expressions.
c. Exaggerate pronunciation of words.
d. Repeat in exactly the same way if child does not understand.
ANS: A
Help the child learn and understand how to read lips by speaking at an even rate. Avoiding using
facial expressions, exaggerating pronunciation of words, and repeating in exactly the same way
if the child does not understand interfere with the childs understanding of the spoken word.
DIF: Cognitive Level: Applying REF: p. 843
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
16. What condition is defined as reduced visual acuity in one eye despite appropriate optical
correction?
a. Myopia
b. Hyperopia
c. Amblyopia
d. Astigmatism
ANS: C
Amblyopia, or lazy eye, is reduced visual acuity in one eye. Amblyopia is usually caused by one
eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be
avoided with the treatment of the primary visual defect such as strabismus. Myopia, or
nearsightedness, refers to the ability to see objects clearly at close range but not a distance.
Hyperopia, or farsightedness, is the ability to see objects at a distance but not at close range.
Astigmatism is unequal curvatures in refractive apparatus.
DIF: Cognitive Level: Understanding REF: p. 844
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
17. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment
includes what intervention?
a. Place a cool compress on eye during transport to the emergency department.
b. Irrigate the eye copiously with a sterile saline solution.
c. Remove the object with a lightly moistened gauze pad.
d. Apply a Fox shield to the affected eye and any type of patch to the other eye.
ANS: D
The nurses role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if
available) should be applied to the injured eye and a regular eye patch to the other eye to prevent
bilateral movement. Placing cool compress on the eye during transport to emergency department,
irrigating eye copiously with a sterile saline solution, or removing object with a lightly
moistened gauze pad may cause more damage to the eye.
DIF: Cognitive Level: Applying REF: p. 847
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
18. A father calls the emergency department nurse saying that his daughters eyes burn after
getting some dishwasher detergent in them. The nurse recommends that the child be seen in the
emergency department or by an ophthalmologist. The nurse also should recommend which action
before the child is transported?
a. Keep the eyes closed.
b. Apply cold compresses.
c. Irrigate the eyes copiously with tap water for 20 minutes.
d. Prepare a normal saline solution (salt and water) and irrigate the eyes for 20 minutes.
ANS: C
The first action is to flush the eyes with clean tap water. This will rinse the detergent from the
eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do
further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the
detergent to cause continued injury to the eyes.
DIF: Cognitive Level: Applying REF: p. 847
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
19. A 5-year-old child has bilateral eye patches in place after surgery yesterday morning. Today
he can be out of bed. What nursing intervention is most important at this time?
a. Speak to him when entering the room.
b. Allow him to assist in feeding himself.
c. Orient him to his immediate surroundings.
d. Reassure him and allow his parents to stay with him.
ANS: C
Safety is the priority concern. Because he can now be out of bed, it is imperative that he knows
about his physical surroundings. Speaking to the child is a component of nursing care that is
expected with all clients unless contraindicated. Unless additional impairments are present, his
meal tray should be set up, and he should be able to feed himself. Reassuring him and allowing
his parents to stay with him are essential parts of nursing care for all children.
DIF: Cognitive Level: Applying REF: p. 849
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
20. Autism is a complex developmental disorder. The diagnostic criteria for autism include
delayed or abnormal functioning in which area with onset before age 3 years?
a. Parallel play
b. Gross motor development
c. Ability to maintain eye contact
d. Growth below the fifth percentile
ANS: C
One hallmark of autism spectrum disorders is the childs inability to maintain eye contact with
another person. Parallel play is play typical of toddlers and is usually not affected. Social, not
gross motor, development is affected by autism. Physical growth and development are not
usually affected.
DIF: Cognitive Level: Understanding REF: p. 845
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
21. What intervention should be included in the nursing care of a child with autism spectrum
disorder (ASD)?
a. Assign multiple staff to care for the child.
b. Communicate with the child at his or her developmental level.
c. Provide a wide variety of foods for the child to try.
d. Place the child in a semiprivate room with a roommate of a similar age.
ANS: B
Children with ASD require individualized care. The nurse needs to communicate with the child
at the childs developmental level. Consistent caregivers are essential for children with ASD. The
same staff members should care for the child as much as possible. Children with ASD do not
adapt to changing situations. The same foods should be provided to allow the child to adjust. A
private room is desirable for children with ASD. Stimulation is minimized.
DIF: Cognitive Level: Applying REF: p. 857
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
22. What suggestion by the nurse for parents regarding stuttering in children is most helpful?
a. Offer rewards for proper speech.
b. Encourage the child to take it easy and go slow when stuttering.
c. Help the child by supplying words when he or she is experiencing a block.
d. Give the child plenty of time and the impression that you are not in a hurry.
ANS: D
Hesitancy and dysfluency should be considered a normal part of speech development. An
important approach is to allow the child plenty of time to speak. Promising rewards for proper
speech places additional pressure on the child. Encouraging the child to take it easy and go slow
when stuttering draws attention to the dysfluency. The child needs to complete a sentence and
thought without being interrupted.
DIF: Cognitive Level: Understanding REF: p. 858
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
23. What observation in a child should indicate the need for a referral to a specialist regarding a
communication impairment?
a. At 2 years of age, the child fails to respond consistently to sounds.
b. At 3 years of age, the child fails to use sentences of more than five words.
c. At 4 years of age, the child has impaired sentence structure.
d. At 5 years of age, the child has poor voice quality.
ANS: A
If a 2-year-old child fails to respond consistently to sounds, it is an indication for referral to a
specialist regarding communication impairment. At age 3 years, the child failing to use sentences
of three words would be an indication for referral; impaired sentence structure would be seen in a
5-year-old child and poor voice quality in an older child who has a communication impairment.
DIF: Cognitive Level: Applying REF: p. 859
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
24. The nurse is performing a physical assessment on a 3-year-old child. The parents state that
the child excessively rubs the eyes and often tilts the head to one side. What visual impairment
should the nurse suspect?
a. Strabismus
b. Astigmatism
c. Hyperopia, or farsightedness
d. Myopia, or nearsightedness
ANS: D
Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading,
headaches, and dizziness. Strabismus, astigmatism, and hyperopia have other clinical
manifestations.
DIF: Cognitive Level: Applying REF: p. 845
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
25. The community nurse is planning prevention measures designed to avoid conditions that can
cause cognitive impairment. Taking folic acid supplements during pregnancy to prevent neural
tube defects is which type of prevention strategy?
a. Primary
b. Secondary
c. Tertiary
d. Rehabilitative
ANS: A
Primary prevention strategies are those designed to avoid conditions that cause cognitive
impairment. Use of folic acid supplements during pregnancy to prevent neural tube defects is a
primary prevention strategy. Secondary prevention activities are those designed to identify the
condition early and initiate treatment to avert cerebral damage. Tertiary prevention strategies are
those concerned with treatment to minimize long-term consequences. Rehabilitation services is
an example of tertiary prevention.
DIF: Cognitive Level: Analyzing REF: p. 825
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
26. The nurse is teaching a preschool child with a cognitive impairment how to throw a ball
overhand. What teaching strategy should the nurse use for this child?
a. Demonstrate how to throw a ball overhand.
b. Explain the reason for throwing a ball overhand.
c. Show pictures of children throwing balls overhand.
d. Explain to the child how to throw the ball overhand.
ANS: A
Children with cognitive impairment have a deficit in discrimination, which means that concrete
ideas are much easier to learn effectively than abstract ideas. Therefore, demonstration is
preferable to verbal explanation, and the nurse should direct learning toward mastering a skill
rather than understanding the scientific principles underlying a procedure. Demonstrating how to
throw the ball is the best teaching strategy.
DIF: Cognitive Level: Applying REF: p. 827
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
27. The camp nurse is choosing a toy for a child with cognitive impairment to play with during
swimming time. What toy should the nurse choose to encourage improvement of developmental
skills?
a. Dive rings
b. An inner tube
c. Floating ducks
d. A large beach ball
ANS: D
Toys are selected for their recreational and educational value. For example, a large inflatable
beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills
such as balance, rocking, kicking, and throwing. Dive rings, an inner tube, and floating ducks are
not interactive toys.
DIF: Cognitive Level: Applying REF: p. 829
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
28. The nurse is teaching feeding strategies to a parent of a 12-month-old infant with Down
syndrome. What statement made by the parent indicates a need for further teaching?
a. If the food is thrust out, I will reefed it.
b. I will use a small, long, straight-handled spoon.
c. I will place the food on the top of the tongue.
d. I know the tongue thrust doesnt indicate a refusal of the food.
ANS: C
Parents of a child with Down syndrome need to know that the tongue thrust does not indicate
refusal to feed but is a physiologic response. Parents are advised to use a small but long, straight-
handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it
should be refed. If the parent indicates placing the food on the tongue, further teaching is needed.
DIF: Cognitive Level: Applying REF: p. 837
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
29. The nurse is counseling a pregnant 35-year-old woman about estimated risk of Down
syndrome. What is the estimated risk for a woman who is 35 years of age?
a. One in 1200
b. One in 900
c. One in 350
d. One in 100
ANS: C
The estimated risk of Down syndrome for a 35-year-old woman is one in 350. One in 1200 is the
risk for a 25-year-old woman, one in 900 is the risk for a 30-yearold woman, and one in 100 is
the risk for a 40-year-old woman.
DIF: Cognitive Level: Applying REF: p. 833
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
30. The nurse is teaching parents of a child with cataracts about the upcoming treatment. The
nurse should give the parents what information about the treatment of cataracts?
a. The treatment may require more than one surgery.
b. It is corrected with biconcave lenses that focus rays on the retina.
c. Cataracts require surgery to remove the cloudy lens and replace it.
d. Treatment is with a corrective lenses; no surgery is necessary.
ANS: C
Treatment for cataracts requires surgery to remove the cloudy lens and replace it (with an
intraocular lens implant, removable contact lens, or prescription glasses). Treatment for
glaucoma may require more than one surgery. Anisometropia is treated with corrective lenses.
Myopia is corrected with biconcave lenses that focus rays on the retina.
DIF: Cognitive Level: Applying REF: p. 846
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
31. What action should the school nurse take for a child who has a hematoma (black eye) with no
hemorrhage into the anterior chamber?
a. Apply a warm moist pack.
b. Have the child keep the eyes open.
c. Apply ice for the first 24 hours.
d. Refer to an ophthalmologist immediately.
ANS: C
The care for a hematoma eye injury with no hemorrhage into the anterior chamber is to apply ice
for the first 24 hours. A warm moist pack should not be applied, and the child should keep the
eyes closed. Referral to an ophthalmologist is recommended if hyphema (hemorrhage into the
anterior chamber) is present.
DIF: Cognitive Level: Applying REF: p. 847
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The nurse is preparing an education program on hearing impairment for a group of new staff
nurses. What concepts should be included? (Select all that apply.)
a. A child with a slight hearing loss is usually unaware of a hearing difficulty.
b. A clinical manifestation of a hearing impairment in children is avoidance of social interaction.
c. A child with a severe hearing loss may hear a loud voice if nearby.
d. Children with sensorineural hearing loss can benefit from the use of a hearing aid.
e. A clinical manifestation of hearing impairment in an infant is lack of the startle reflex.
f. Identification of a hearing loss after the first year is essential to facilitate language development in children.
ANS: A, B, C, E
When discussing hearing impairment in children, the nurse should include information about
differences in hearing losses, such as with a slight hearing loss, the child is usually unaware of a
hearing difficulty, and with a severe loss, the child may hear a loud noise if it is nearby. An infant
with a hearing loss may lack the startle response, and a hearing impaired child may avoid social
interaction. Children with a sensorineural hearing loss would not benefit from a hearing aid.
Identification of a hearing loss is imperative in the first 3 to 6 months to facilitate language and
educational development for children.
DIF: Cognitive Level: Analyzing REF: p. 842
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
2. The nurse understands that which gestational disorders can cause a cognitive impairment in
the newborn? (Select all that apply.)
a. Prematurity
b. Postmaturity
c. Low birth weight
d. Physiological jaundice
e. Large for gestational age
ANS: A, B, C
Prematurity, postmaturity, and low birth weight can be causes of cognitive impairment in
newborns. Physiological jaundice and large for gestational age are not associated causes of
cognitive impairment in newborns.
DIF: Cognitive Level: Understanding REF: p. 825
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. The clinic nurse is assessing an infant. What are early signs of cognitive impairment the nurse
should discuss with the health care provider? (Select all that apply.)
a. Head lag at 11 months of age
b. No pincer grasp at 4 months of age
c. Colicky incidents at 3 months of age
d. Unable to speak two to three words at 24 months of age
e. Unresponsiveness to the environment at 12 months of age
ANS: A, D, E
Early signs of cognitive impairment include gross motor delay (head lag should be established by
6 months, and head lag still present at 11 months is a delay), language delay (normal language
development is speaking two to three words by age 12 months; if unable to speak two to three
words at 24 months, that is a delay), and unresponsiveness to the environment at 12 months. No
pincer grasp at 4 months of age is normal (palmar grasp is the expected finding), and colicky
incidents at 3 months of age is a normal finding.
DIF: Cognitive Level: Analyzing REF: p. 826
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is teaching parents of a child with a cognitive impairment signs that indicate the
child is developmentally ready for dressing training. What signs should the nurse include that
indicate the child is developmentally ready for dressing training? (Select all that apply.)
a. Can follow verbal commands
b. Can sit quietly for 1 to 2 minutes
c. Can master every task of dressing
d. Can follow physical gestures or cues
e. Can relate clothing to the appropriate body part
ANS: A, D, E
Children are considered developmentally ready for dressing training if they can sit quietly for 3
to 5 minutes (not 1 to 2) while working on a task; can follow physical gestures or cues; can
follow verbal commands; and can relate clothing to the appropriate body part, such as socks to
feet. As with other self-help skills, the child may not be able to master every task but should be
evaluated for evidence of willingness to participate at his or her level of readiness.
DIF: Cognitive Level: Applying REF: p. 832
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse is assessing a child with Down syndrome. The nurse recognizes that which are
possible comorbidities that can occur with Down syndrome? (Select all that apply.)
a. Diabetes mellitus
b. Hodgkins disease
c. Congenital heart defects
d. Respiratory tract infections
e. Acute megakaryoblastic leukemia
ANS: C, D, E
Children with Down syndrome often have multiple comorbidities, contributing to numerous
other conditions. Respiratory tract infections are prevalent; when combined with cardiac
anomalies, they are the chief cause of death, particularly during the first year. The incidence of
leukemia is several times more frequent than expected in the general population, and in about
half of the cases, the type is acute megakaryoblastic leukemia.
DIF: Cognitive Level: Analyzing REF: p. 835
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. A child has a slight (2640 dB) degree of hearing loss. The nurse recognizes this amount of
hearing loss can have what effect? (Select all that apply.)
a. No speech defects
b. Difficulty hearing faint speech
c. Usually is unaware of the hearing difficulty
d. Can distinguish vowels but not consonants
e. Unable to understand conversational speech
ANS: A, B, C
A child with a slight degree of hearing loss has no speech defects, may have difficulty hearing
faint speech, and is usually unaware of the hearing difficulty. The ability to distinguish vowels
but not consonants is an effect of severe hearing loss and being unable to understand
conversational speech is an effect of moderately severe hearing loss.
DIF: Cognitive Level: Analyzing REF: p. 840
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
7. What risk factors can cause a sensorineural hearing impairment in an infant? (Select all that
apply.)
a. Cat scratch disease
b. Bacterial meningitis
c. Childhood case of measles
d. Childhood case of chicken pox
e. Administration of aminoglycosides for more than 5 days
ANS: B, C, E
Risk criteria for sensorineural hearing impairment in infants include bacterial meningitis; a case
of measles; and administration of ototoxic medications (e.g., gentamicin, tobramycin,
kanamycin, streptomycin), including but not limited to the aminoglycosides, for more than 5
days. Cat scratch disease and a childhood case of chicken pox are not risk factors that can cause
a sensorineural hearing impairment.
DIF: Cognitive Level: Understanding REF: p. 841
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. The nurse is teaching parents the signs of a hearing impairment in infants. What should the
nurse include as signs? (Select all that apply.)
a. Lack of a fencing reflex
b. Lack of a startle reflex to a loud sound
c. Awakened by loud environmental noises
d. Failure to localize a sound by 6 months of age
e. Response to loud noises as opposed to the voice
ANS: B, D, E
The fencing reflex is elicited when the infant is placed on his or her back; it does not indicate a
hearing impairment. Awakening by a loud environmental noise is a normal response.
DIF: Cognitive Level: Applying REF: p. 842
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
9. The nurse is teaching parents the signs of a hearing impairment in a child. What should the
nurse include as signs? (Select all that apply.)
a. Outgoing behavior
b. Yelling to express pleasure
c. Asking to have statements repeated
d. Foot stamping for vibratory sensation
e. Failure to develop intelligible speech by age 24 months
ANS: B, C, D, E
Signs of a hearing impairment in a child include yelling to express pleasure, asking to have
statements repeated, foot stamping for vibratory sensation, and failure to develop intelligible
speech by age 24 months. The childs behavior is shy, not outgoing.
DIF: Cognitive Level: Applying REF: p. 842
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
10. The nurse should plan which actions to assist the stuttering child? (Select all that apply.)
a. Ask the child to stop and start over.
b. Promise a reward for proper speech.
c. Set a good example by speaking clearly.
d. Give the child plenty of time to finish sentences.
e. Look directly at the child while he or she is speaking.
ANS: C, D, E
Actions to be encouraged to help the stuttering child include setting a good example by speaking
clearly, giving the child plenty of time to finish sentences, and looking directly at the child while
he or she is speaking. Asking the child to stop and start over and promising a reward for proper
speech are actions to be avoided with stuttering children.
DIF: Cognitive Level: Applying REF: p. 858 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
11. The nurse should plan which actions to facilitate lipreading for a child with a hearing
impairment? (Select all that apply.)
a. Face the child directly.
b. Speak at eye level.
c. Keep sentences short.
d. Speak at a fast, even-paced rate.
e. Establish eye contact and show interest.
ANS: A, B, C, E
To facilitate lipreading, the nurse should plan to face the child directly, speak at eye level, keep
sentences short, and establish eye contact and show interest. The nurse should plan to speak at a
slow rate, not a fast one.
DIF: Cognitive Level: Applying REF: p. 843 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
12. What are indications for a referral regarding a communication impairment in a school-age
child? (Select all that apply.)
a. Barely audible voice quality
b. Vocal pitch inappropriate for age
c. Intonation noted during speaking
d. Maintains a rhythm while speaking
e. Distortion of sounds after age 7 years
ANS: A, B, E
Barely audible voice quality, vocal pitch inappropriate for age, and distortion of sounds after age
7 years are indications for a referral regarding a communication impairment. Intonation noted
while speaking and maintaining a rhythm while speaking are normal characteristics of speech.
DIF: Cognitive Level: Understanding REF: p. 859
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
MATCHING
Match the type of visual impairment to its definition.
a. Myopia
b. Hyperopia
c. Astigmatism
d. Anisometropia
e. Amblyopia
1. Different refractive strength in each eye
2. Ability to see objects clearly at close range but not at a distance
3. Reduced visual acuity in one eye
4. Unequal curvatures in refractive apparatus
5. Ability to see objects at a distance but not at a close range
Family-Centered Care of the Child with Chronic Illness or
Disability
MULTIPLE CHOICE
1. What is the major health concern of children in the United States?
a. Acute illness
b. Chronic illness
c. Congenital disabilities
d. Nervous system disorders
ANS: B
An estimated 18% of children in the United States have a chronic illness or disability that
warrants health care services beyond those usually required by children. Chronic illness has
surpassed acute illness as the major health concern for children. Congenital disabilities exist
from birth but may not be hereditary. These represent a portion of the number of children with
chronic illnesses. Mental and nervous system disorders account for approximately 17% of
chronic illnesses in children.
DIF: Cognitive Level: Understanding REF: p. 761 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
2. What is a major premise of family-centered care?
a. The child is the focus of all interventions.
b. Nurses are the authorities in the childs care.
c. Parents are the experts in caring for their child.
d. Decisions are made for the family to reduce stress.
ANS: C
As parents become increasingly responsible for their children, they are the experts. It is essential
that the health care team recognize the familys expertise. In family-centered care, consistent
attention is given to the effects of the childs chronic illness on all family members, not just the
child. Nurses are adjuncts in the childs care. The nurse builds alliances with parents. Family
members are involved in decision making about the childs physical care.
DIF: Cognitive Level: Analyzing REF: p. 762
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. What should the nurse determine to be the priority intervention for a family with an infant who
has a disability?
a. Focus on the childs disabilities to understand care needs.
b. Institute age-appropriate discipline and limit setting.
c. Enforce visiting hours to allow parents to have respite care.
d. Foster feelings of competency by helping parents learn the special care needs of the infant.
ANS: D
It is important that the parents learn how to care for their infant so they feel competent. The nurse
facilitates this by teaching special holding techniques, supporting breastfeeding, and encouraging
frequent visiting and rooming in. The focus should be on the infants capabilities and positive
features. Infants do not usually require discipline. As the child gets older, this is necessary, but it
is not a priority intervention at this time. The nursing staff negotiates with the family about the
need for respite care.
DIF: Cognitive Level: Analyzing REF: p. 763
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
4. The potential effects of chronic illness or disability on a childs development vary at different
ages. What developmental alteration is a threat to a toddlers normal development?
a. Hindered mobility
b. Limited opportunities for socialization
c. Childs sense of guilt that he or she caused the illness or disability
d. Limited opportunities for success in mastering toilet training
ANS: A
Toddlers are acquiring a sense of autonomy, developing self-control, and forming symbolic
representation through language acquisition. Mobility is the primary tool used by toddlers to
experiment with maintaining control. Loss of mobility can create a sense of helplessness.
Toddlers do not socialize. They are sensitive to changes in family routines. A sense of guilt is
more likely to occur in a preschooler. Toilet training is not usually mastered until the end of the
toddler period.
DIF: Cognitive Level: Understanding REF: p. 768 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
5. A feeling of guilt that the child caused the disability or illness is especially common in which
age group?
a. Toddler
b. Preschooler
c. School-age child
d. Adolescent
ANS: B
Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or
disability or are being punished for wrongdoings. Toddlers are focused on establishing their
autonomy. The illness fosters dependency. School-age children have limited opportunities for
achievement and may not be able to understand limitations. Adolescents face the task of
incorporating their disabilities into their changing self-concept.
DIF: Cognitive Level: Understanding REF: p. 769
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
6. What intervention is most appropriate for fostering the development of a school-age child with
disabilities associated with cerebral palsy?
a. Provide sensory experiences.
b. Help develop abstract thinking.
c. Encourage socialization with peers.
d. Give choices to allow for feeling of control.
ANS: C
Peer interaction is especially important in relation to cognitive development, social development,
and maturation. Cognitive development is facilitated by interaction with peers, parents, and
teachers. The identification with those outside the family helps the child fulfill the striving for
independence. Sensory experiences are beneficial, especially for younger children. School-age
children are too young for abstract thinking. Giving school-age children choices is always an
important intervention. Providing structured choices allows for a feeling of control.
DIF: Cognitive Level: Applying REF: p. 763
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
7. A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks
such as missing doses of his medication. What should the nurse explain to his parents?
a. That he needs more discipline
b. That this is a normal part of adolescence
c. That he needs more socialization with peers
d. That this is how he is asking for more parental control
ANS: B
Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence, during
which young adults are establishing independence. If the parents increase the amount of
discipline, he will most likely be more rebellious. More socialization with peers does not address
the problem of risk-taking behavior.
DIF: Cognitive Level: Applying REF: p. 767
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
8. What nursing intervention is most appropriate in promoting normalization in a school-age
child with a chronic illness?
a. Give the child as much control as possible.
b. Ask the childs peer to make the child feel normal.
c. Convince the child that nothing is wrong with him or her.
d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings.
ANS: A
The school-age child who is ill may be forced into a period of dependency. To foster normalcy,
the child should be given as much control as possible. It is unrealistic for one individual to make
the child feel normal. The child has a chronic illness, so it would be unacceptable to convince the
child that nothing is wrong. The family rules should be similar for each of the children in a
family. Resentment and hostility can arise if different standards are applied to each child.
DIF: Cognitive Level: Applying REF: p. 769
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
9. The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse
should recognize that this is most likely an indication that the child is experiencing what
emotional response?
a. Hopefulness
b. Chronic sorrow
c. Belief that procedures are a deserved punishment
d. Understanding that procedures indicate impending death
ANS: C
The nurse should be particularly alert to a child who withdraws and passively accepts all painful
procedures. This child may believe that such acts are inflicted as deserved punishment for being
less worthy. A child who is hopeful is mobilized into goal-directed actions. This child would
actively participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves
over time. It is usually evident in the parents, not in the child. The seriously ill child would
actively participate in care. Nursing interventions should be used to minimize the pain.
DIF: Cognitive Level: Analyzing REF: p. 774
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
10. The parents of a child born with disabilities ask the nurse for advice about discipline. The
nurses response should be based on remembering that discipline is which?
a. Essential for the child
b. Not needed unless the childs behavior becomes problematic
c. Best achieved with punishment for misbehavior
d. Too difficult to implement with a special needs child
ANS: A
Discipline is essential for the child. It provides boundaries on which she can test out her behavior
and teaches her socially acceptable behaviors. The nurse should teach the parents ways to
manage the childs behavior before it becomes problematic. Punishment is not effective in
managing behavior.
DIF: Cognitive Level: Applying REF: p. 777
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
11. Parents ask for help for their other children to cope with the changes in the family resulting
from the special needs of their sibling. What strategy does the nurse recommend?
a. Explain to the siblings that embarrassment is unhealthy.
b. Encourage the parents not to expect siblings to help them care for the child with special needs.
c. Provide information to the siblings about the childs condition only as requested.
d. Invite the siblings to attend meetings to develop plans for the child with special needs.
ANS: D
Siblings should be invited to attend meeting to be part of the care team for the child. They can
learn about an individualized education plan and help design strategies that will work at home.
Embarrassment may be associated with having a sibling with a chronic illness or disability.
Parents must be able to respond in an appropriate manner without punishing the sibling. The
parents may need assistance with the care of the child. Most siblings are positive about the extra
responsibilities. Parents need to inform the siblings about the childs condition before a nonfamily
member does so. The parents do not want the siblings to fantasize about what is wrong with the
child.
DIF: Cognitive Level: Analyzing REF: p. 780
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
12. The nurse is assessing the coping behaviors of the parents of a child recently diagnosed with
a chronic illness. What behavior should the nurse consider an approach behavior that results in
movement toward adjustment?
a. Being unable to adjust to a progression of the disease or condition
b. Anticipating future problems and seeking guidance and answers
c. Looking for new cures without a perspective toward possible benefit
d. Failing to recognize the seriousness of the childs condition despite physical evidence
ANS: B
The parents who anticipate future problems and seek guidance and answers are demonstrating
approach behaviors. These are positive actions in caring for their child. Being unable to adjust,
looking for new cures, and failing to recognize the seriousness of the childs condition are
avoidance behaviors. The parents are moving away from adjustment or exhibiting maladaptation
to the crisis of a child with chronic illness or disability.
DIF: Cognitive Level: Analyzing REF: p. 783
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
13. What nursing intervention is especially helpful in assessing feelings of parental guilt when a
disability or chronic illness is diagnosed?
a. Ask the parents if they feel guilty.
b. Observe for signs of overprotectiveness.
c. Talk about guilt only after the parents mention it.
d. Discuss the meaning of the parents religious and cultural background.
ANS: D
Guilt may be associated with cultural or religious beliefs. Some parents are convinced that they
are being punished for some previous misdeed. Others may see the disorder as a trial sent by God
to test their religious beliefs. The nurse can help the parents explore their religious beliefs. On
direct questioning, the parents may not be able to identify the feelings of guilt. It would be
appropriate for the nurse to explore their adjustment responses. Overprotectiveness is a parental
response during the adjustment phase. The parents fear letting the child achieve any new skill
and avoid all discipline.
DIF: Cognitive Level: Analyzing REF: p. 784
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
14. Families progress through various stages of reactions when a child is diagnosed with a
chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is
often characterized by what response?
a. Denial
b. Guilt and anger
c. Social reintegration
d. Acceptance of the childs limitations
ANS: B
For most families, the adjustment phase is accompanied by several responses, including guilt,
self-accusation, bitterness, and anger. The initial diagnosis of a chronic illness or disability often
is met with intense emotion and characterized by shock and denial. Social reintegration and
acceptance of the childs limitations are the culmination of the adjustment process.
DIF: Cognitive Level: Understanding REF: p. 785 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
15. What manifestation observed by the nurse is suggestive of parental overprotection?
a. Gives inconsistent discipline
b. Facilitates the childs responsibility for self-care of illness
c. Persuades the child to take on activities of daily living even when not able
d. Encourages social and educational activities not appropriate to the childs level of capability
ANS: A
Parental overprotection is manifested when the parents fear letting the child achieve any new
skill, avoid all discipline, and cater to every desire to prevent frustration. Overprotective parents
do not allow the child to assume responsibility for self-care of the illness. The parents prefer to
remain in the role of total caregiver. The parents do not encourage the child to participate in
social and educational activities.
DIF: Cognitive Level: Analyzing REF: p. 785
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
16. What finding by the nurse is most characteristic of chronic sorrow?
a. Lack of acceptance of childs limitation
b. Lack of available support to prevent sorrow
c. Periods of intensified sorrow when experiencing anger and guilt
d. Periods of intensified sorrow at certain landmarks of the childs development
ANS: D
Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The
sorrow is a response to the recognition of the childs limitations. The family should be assessed in
an ongoing manner to provide appropriate support as their needs change. The sorrow is not
preventable. The chronic sorrow occurs during the reintegration and acknowledgment stage.
DIF: Cognitive Level: Analyzing REF: p. 785
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
17. A 5-year-old child will be starting kindergarten next month. She has cerebral palsy, and it has
been determined that she needs to be in a special education classroom. Her parents are tearful
when telling the nurse about this and state that they did not realize her disability was so severe.
What is the best interpretation of this situation?
a. This is a sign the parents are in denial.
b. This is a normal anticipated time of parental stress.
c. The parents need to learn more about cerebral palsy.
d. The parents expectations are too high.
ANS: B
Parenting a child with a chronic illness can be stressful. At certain anticipated times, parental
stress increases. One of these identified times is when the child begins school. Nurses can help
parents recognize and plan interventions to work through these stressful periods. The parents are
not in denial; rather, they are responding to the childs placement in school. The parents are not
exhibiting signs of a remembering deficit; this is their first interaction with the school system
with this child.
DIF: Cognitive Level: Analyzing REF: p. 778
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
18. The nurse notes that the parents of a critically ill child spend a large amount of time talking
with the parents of another child who is also seriously ill. They talk with these parents more than
with the nurses. How should the nurse interpret this situation?
a. Parent-to-parent support is valuable.
b. Dependence on other parents in crisis is unhealthy.
c. This is occurring because the nurses are unresponsive to the parents.
d. This has the potential to increase friction between the parents and nursing staff.
ANS: A
Veteran parents share experiences that cannot be supplied by other support systems. They have
known the stress related to diagnosis, have weathered the many transition times, and have a
practical remembering of resources. The parents can be mutually supportive during times of
crisis. Nursing staff cannot provide the type of support that is realized from other parents who are
experiencing similar situations. Friction should not exist between the nursing staff and the family
of the child who is critically ill.
DIF: Cognitive Level: Applying REF: p. 787 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
19. The nurse is talking to the parent of a child with special needs. The parent has expressed
worry about how to support the siblings at home. What suggestion is appropriate for the nurse to
give to the parent?
a. You should help the siblings see the similarities and differences between themselves and your child with special needs.
b. You should explain that your child with special needs should be included in all activities that the siblings participate in even if they are reluctant.
c. You should give the siblings many caregiving tasks for your child with special needs so the siblings feel involved.
d. You should intervene when there are differences between your child with special needs and the siblings.
ANS: A
Appropriate information to give to a parent who wants to support the siblings of a child with
special needs includes helping the siblings see the differences and similarities between
themselves and the child with special needs to promote an understanding environment. The
parent should be encouraged to allow the siblings to participate in activities that do not always
include the child with special needs, to limit caregiving responsibilities, and to allow the children
to settle their own differences rather than step in all the time.
DIF: Cognitive Level: Applying REF: p. 779 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
20. What is the single most prevalent cause of disability in children and responsible for the
recent increase in childhood disability?
a. Cancer
b. Asthma
c. Seizures
d. Heart disease
ANS: B
Asthma is the single most prevalent cause of disability in children and has been largely
responsible for much of the recent increase in childhood disability.
DIF: Cognitive Level: Understanding REF: p. 762
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
21. The parents of a child on a ventilator tell the nurse that their insurance company wants the
child to be discharged. They explain that they do not want the child home under any
circumstances. What principle should the nurse consider when working with this family?
a. Desire to have the child home is essential to effective home care.
b. Parents should not be expected to care for a technology-dependent child.
c. Having a technology-dependent child at home is better for both the child and the family.
d. Parents are not part of the decision-making process because of the costs of hospitalization.
ANS: A
Home care requires the family to manage the childs illness, including providing daily hands-on
care, monitoring the childs medical condition, and educating others to care for the child. The
childs home environment with the childs family is perceived as the best place for the child to be
cared for. If the family does not want to or is not able to assume these responsibilities, other
arrangements need to be investigated. The family is an essential part of the decision-making
process. Without family involvement and support, the technology-dependent child will not be
well cared for at home.
DIF: Cognitive Level: Understanding REF: p. 763 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
22. A child with a serious chronic illness will soon go home. The case manager requests that the
family provide total care for the child for a couple of days while the child is still hospitalized.
How should the request be viewed?
a. Improper because of legal issues
b. Supportive because families are usually eager to get involved
c. Unacceptable because the family will have to assume the care soon enough
d. Important because it can be beneficial to the transition from hospital to home
ANS: D
This type of groundwork is essential for the family. Adequate family training and preparation
will assist in the childs transition home. The nursing staff in the hospital is responsible for the
childs care. The family will provide the care with assistance as needed. Although parents are
eager to be involved, the purpose of this intervention is the development of family competency
and confidence that they are capable. Arrangements for respite care are important for the family
both during hospitalizations and while the child is at home.
DIF: Cognitive Level: Understanding REF: p. 778 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
23. For case management to be most effective, who should be recognized as the most appropriate
case manager?
a. Nurse
b. Panel of experts
c. Multidisciplinary team
d. Insurance company
ANS: A
Nursing case managers are ideally suited to provide the care coordination necessary. Care
coordination is most effective if a single person works with the family to accomplish the many
tasks and responsibilities that are necessary. The family retains the role as primary decision
maker. Most likely the insurance company will have a case manager focusing on the financial
aspects of care. This does not include coordination of care to assist the family.
DIF: Cognitive Level: Understanding REF: p. 782 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
24. An adolescent with long-term, complex health care needs will soon be discharged from the
hospital. The nurse case manager has been assigned to the teen and family. The adolescents care
involves physical therapy, occupational therapy, and speech therapy in addition to medical and
nursing care. Who should be the decision maker in the adolescents care?
a. Adolescent
b. Nurse case manager
c. Adolescent and family
d. Multidisciplinary health care team
ANS: C
The extent to which children are involved in their own care and decision making depends on
many factors, including the childs developmental age, level of interest, physical ability, and
parental support. If the adolescent is developmentally age appropriate, then decision making
should be the responsibility of child and family. Family needs to be involved because they will
be caring for the adolescent in the home. Health care providers have necessary input into the care
of the child, but ultimate decision making rests with the adolescent and family.
DIF: Cognitive Level: Applying REF: p. 767 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
25. The nurse has been assigned as a home health nurse for a child who is technology dependent.
The nurse recognizes that the familys background differs widely from the nurses own. The nurse
believes some of their lifestyle choices are less than ideal. What nursing intervention is most
appropriate to institute?
a. Change the family.
b. Respect the differences.
c. Assess why the family is different.
d. Determine whether the family is dysfunctional.
ANS: B
Respect for varied family structures and for racial, ethnic, cultural, and socioeconomic diversity
among families is essential in home care. The nurse must assess and respect the familys
background and lifestyle choices. It is not appropriate to attempt to change the family. The nurse
is a guest in the home and care of the child. The family and the values held by the cultural group
prevail. The nurse may assess why the family is different to help the nurse and other health
professionals understand the differences. It is not appropriate to determine whether the family is
dysfunctional.
DIF: Cognitive Level: Applying REF: p. 774
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
26. A childs parents ask the nurse many questions about their childs illness and its management.
The nurse does not know enough to answer all the questions. What nursing action is most
appropriate at this time?
a. Tell them, I dont know, but I will find out.
b. Suggest that they ask the physician these questions.
c. Explain that the nurse cannot be expected to know everything.
d. Answer questions vaguely so they do not lose confidence in the nurse.
ANS: A
Questions from parents should be answered in a straightforward manner. Stating I dont know or
Ill find out is better than pretending to know or giving excuses. Suggesting that they ask the
physician these questions is not supportive of the family. The nurses role is to assist the parents
in obtaining accurate information about their childs illness and its management. Although the
nurse cannot be expected to know everything, it is an unprofessional attitude to state this. Nurses
must provide accurate information to the extent possible. Vague answers are not helpful to the
family.
DIF: Cognitive Level: Applying REF: p. 775
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Safe and Effective Care Environment
27. The nurse outlines short- and long-term goals for a 10-year-old child with many complex
health problems. Who should agree on these goals?
a. Family and nurse
b. Child, family, and nurse
c. All professionals involved
d. Child, family, and all professionals involved
ANS: D
In the home, the family is a partner in each step of the nursing process. The family priorities
should guide the planning process. Both short- and long-term goals should be outlined and
agreed on by the child, family, and professionals involved. Elimination of any one of these
groups can potentially create a care plan that does not meet the needs of the child and family.
DIF: Cognitive Level: Analyzing REF: p. 777 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
28. When communicating with other professionals about a child with a chronic illness, what is
important for nurses to do?
a. Ask others what they want to know.
b. Share everything known about the family.
c. Restrict communication to clinically relevant information.
d. Recognize that confidentiality is not possible in home care.
ANS: C
The nurse needs to share, through both oral and written communication, clinically relevant
information with other involved health professionals. Asking others what they want to know and
sharing everything known about the family are inappropriate measures. Patients have a right to
confidentiality. Confidentiality permits the disclosure of information to other health professionals
on a need-to-know basis.
DIF: Cognitive Level: Applying REF: p. 761
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
29. The nurse has been visiting an adolescent with recently acquired tetraplegia. The teens
mother tells the nurse, Im sick of providing all the care while my husband does whatever he
wants to, whenever he wants to do it. What reaction should be the nurses initial response?
a. Refer the mother for counseling.
b. Listen and reflect the mothers feelings.
c. Ask the father in private why he does not help.
d. Suggest ways the mother can get her husband to help.
ANS: B
It is appropriate for the nurse to reflect with the mother about her feelings, exploring solutions
such as an additional home health aide to help care for the child and provide respite for the
mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping
enough. This judgment is beyond the role of the nurse and can undermine the family relationship.
Counseling, if indicated, would be necessary for both parents. A support group for caregivers
may be indicated. The nurse should not ask the father in private why he does not help or suggest
way the mother can get her husband to help. These interventions are based on the mothers
perceptions; the father may have a full-time job and other commitments. The parents may need
an unbiased third person to help them through the negotiation of their new parenting
responsibilities.
DIF: Cognitive Level: Applying REF: p. 763
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Psychosocial Integrity
30. The nurse is planning care for a 3-year-old boy who has Down syndrome and is on
continuous oxygen. He recently began walking around furniture. He is spoon fed by his parents
and eats some finger foods. What goal is the most appropriate to promote normal development?
a. Encourage mobility.
b. Encourage assistance in self-care.
c. Promote oral-motor development.
d. Provide opportunities for socialization.
ANS: A
A major principle for developmental support in children with complex medical issues is that it
should be flexible and tailored to the individual childs abilities, interests, and needs. This child is
exhibiting readiness for ambulation. It is an appropriate time to provide activities that encourage
mobility, for example, longer oxygen tubing. Parents should provide decreasing amounts of
assistance with self-care as he is able to develop these skills. The boy is receiving oral foods and
is eating finger foods. He has acquired this skill. Mobility is a new developmental task.
Opportunities for socialization should be ongoing.
DIF: Cognitive Level: Applying REF: p. 763 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
31. What behavior seen in children should be addressed by the nurse who is providing care to a
child with a chronic illness?
a. An infant who is uncooperative
b. A toddler who expresses loneliness
c. A preschooler who refuses to participate in self-care
d. An adolescent who is showing independence
ANS: C
Preschoolers thrive on being independent and are in the phase of gaining autonomy, so they want
to perform as many self-care tasks as possible. If a preschooler is refusing to participate in self-
care activities, then the home health nurse should address this. Infants are uncooperative by
nature, and toddlers do not understand the concept of loneliness, so these are not observations
that would need to be addressed. Adolescents are always striving for independence, so this is a
normal observation; if the adolescent were becoming more dependent on family, it might require
intervention.
DIF: Cognitive Level: Applying REF: p. 768
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
32. The nurse asks the mother of a child with a chronic illness many questions as part of the
assessment. The mother answers several questions, then stops and says, I dont know why you ask
me all this. Who gets to know this information? The nurse should respond in what manner?
a. Determine why the mother is so suspicious.
b. Determine what the mother does not want to tell.
c. Explain who will have access to the information.
d. Explain that everything is confidential and that no one else will know what is said.
ANS: C
Communication with the family should not be invasive. The nurse needs to explain the
importance of collecting the information, its applicability to the childs care, and who will have
access to the information. The mother is not being suspicious and is not necessarily withholding
important information. She has a right to understand how the information she provides will be
used. The nurse will need to share, through both oral and written communication, clinically
relevant information with other involved health professionals.
DIF: Cognitive Level: Applying REF: p. 773
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Safe and Effective Care Environment
33. One of the supervisors for a home health agency asks the nurse to give a family of a child
with a chronic illness a survey evaluating the nurses and other service providers. How should the
nurse recognize this request?
a. Appropriate to improve quality of care
b. Improper because it is an invasion of privacy
c. Inappropriate unless nurses and other providers agree to participate
d. Not acceptable because the family lacks remembering necessary to evaluate professionals
ANS: A
Quality assessment and improvement activities are essential for virtually all organizations.
Family involvement in evaluating a home care plan can occur on several levels. The nurse can
ask the family open-ended questions at regular intervals to assess their opinion of the
effectiveness of care. Families should also be given an opportunity to evaluate the individual
home care nurses, the home care agency, and other service providers periodically. Evaluation of
the provision of care to the patient and family requires evaluation of the care provider, that is, the
nurse. Quality-monitoring activities are required by virtually all health care agencies. During the
evaluation process, the family is asked to provide their perceptions of care.
DIF: Cognitive Level: Applying REF: p. 763
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The nurse is planning to use an interpreter with a nonEnglish-speaking family. What should
the nurse plan with regard to the use of an interpreter? (Select all that apply.)
a. Use a family member.
b. The nurse should speak slowly.
c. Use an interpreter familiar with the familys culture.
d. The nurse should speak only a few sentences at a time.
e. The nurse should speak to the interpreter during interactions.
ANS: B, C, D
When parents who do not speak English are informed of their childs chronic illness, interpreters
familiar with both their culture and language should be used. The nurse should speak slowly and
only use a few sentences at a time. Children, family members, and friends of the family should
not be used as translators because their presence may prevent parents from openly discussing the
issues. The nurse should speak to the family, not the interpreter.
DIF: Cognitive Level: Applying REF: p. 765
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Health Promotion and Maintenance
2. The nurse is teaching coping strategies to parents of a child with a chronic illness. What
coping strategies should the nurse include?(Select all that apply.)
a. Listen to the child.
b. Accept the childs illness.
c. Establish a support system.
d. Learn to care for the childs illness one day at a time.
e. Do not share information with the child about the illness.
ANS: A, B, C, D
Coping strategies for parents caring for a child with a chronic illness include listening to the
child, accepting the childs illness, establishing a support system, and learning to care for the
childs illness one day at a time. Information should be shared with the child about the illness.
DIF: Cognitive Level: Applying REF: p. 782
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
3. What are supportive interventions that can assist an infant with a chronic illness to meet
developmental milestones? (Select all that apply.)
a. Encourage consistent caregivers.
b. Encourage periodic respite from demands of care.
c. Encourage one family member to be the primary caretaker.
d. Encourage parental rooming in during hospitalization.
e. Withhold age-appropriate developmental tasks until the child is older.
ANS: A, B, D
To develop trust, consistent caretakers and parents rooming in should be encouraged. To develop
a sense of separateness from parents, periodic respites from caregiving should be encouraged. All
members of the family, not one primary caretaker, should be encouraged to participate in care.
Age-appropriate developmental tasks should be encouraged, not withheld until an older age.
DIF: Cognitive Level: Analyzing REF: p. 766
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is assessing coping behaviors of a family with a child with a chronic illness. What
indicates approach coping behaviors?(Select all that apply.)
a. Plans realistically for the future
b. Verbalizes possible loss of the child
c. Uses magical thinking and fantasy
d. Realistically perceives the childs condition
e. Does not share the burden of the disorder with others
ANS: A, B, D
Approach coping behaviors include planning realistically for the future, verbalizing possible loss
of a child, and realistically perceiving the childs behavior. Using magical thinking and fantasy is
an avoidance behavior. The family should share the burden of the disorder with others as an
approach behavior.
DIF: Cognitive Level: Analyzing REF: p. 783
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
5. What are supportive interventions that can assist a toddler with a chronic illness to meet
developmental milestones? (Select all that apply.)
a. Give choices.
b. Provide sensory experiences.
c. Avoid discipline and limit setting.
d. Discourage negative and ritualistic behaviors.
e. Encourage independence in as many areas as possible.
ANS: A, B, E
To encourage autonomy, choices should be given and independence encouraged in as many areas
as possible. Sensory experiences should be encouraged to help the toddler to learn through
sensorimotor experiences. Age-appropriate discipline and limit setting should be initiated.
Negative and ritualistic behaviors are normal and should be allowed.
DIF: Cognitive Level: Analyzing REF: p. 766
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
6. The nurse is assessing coping behaviors of a family with a child with a chronic illness. What
indicates avoidance coping behaviors?(Select all that apply.)
a. Refuses to agree to treatment
b. Avoids staff, family members, or child
c. Is unable to discuss possible loss of the child
d. Recognizes own growth through a passage of time
e. Makes no change in lifestyle to meet the needs of other family members
ANS: A, B, C, E
Avoidance coping behaviors include refusing to agree to treatment; avoiding staff, family
members, or child; unable to discuss possible loss of the child; and making no change in lifestyle
to meet the needs of other family members. Recognizing ones own growth through a passage of
time is an approach behavior.
DIF: Cognitive Level: Analyzing REF: p. 783
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
7. What are supportive interventions that can assist a preschooler with a chronic illness to meet
developmental milestones? (Select all that apply.)
a. Encourage socialization.
b. Encourage mastery of self-help skills.
c. Provide devices that make tasks easier.
d. Clarify that the cause of the childs illness is not his or her fault.
e. Discuss planning for the future and how the condition can affect choices.
ANS: A, B, C, D
To encourage initiative, mastery of self-help skills should be encouraged, and devices should be
provided that make tasks easier. To develop peer relationships, socialization should be
encouraged. To develop body image, the fact that the cause of the childs illness is not the fault of
the child should be emphasized. Discussing planning for the future and how the condition can
affect choices is appropriate for an adolescent.
DIF: Cognitive Level: Analyzing REF: p. 766
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. The parent of a child with a chronic illness tells the nurse, I feel so hopeless in this situation.
The nurse should take which actions to foster hopefulness for the family? (Select all that apply.)
a. Avoid topics that are lighthearted.
b. Convey a personal interest in the child.
c. Be honest when reporting on the childs condition.
d. Do not initiate any playful interaction with the child.
e. Demonstrate competence and gentleness when delivering care.
ANS: B, C, E
To foster hopefulness, the nurse should convey a personal interest in the child, be honest when
reporting on a childs condition, and demonstrate competence and gentleness when delivering
care. The nurse should introduce conversations on neutral, nondisease-related, or less sensitive
topics (discuss the childs favorite sports, tell stories). The nurse should be lighthearted and
initiate or respond to teasing or other playful interactions with the child.
DIF: Cognitive Level: Applying REF: p. 767
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
9. What are supportive interventions that can assist a school-age child with a chronic illness to
meet developmental milestones? (Select all that apply.)
a. Encourage socialization.
b. Discourage sports activities.
c. Encourage school attendance.
d. Provide instructions on assertiveness.
e. Educate teachers and classmates about the childs condition.
ANS: A, C, E
To develop a sense of accomplishment, school attendance should be encouraged, and teachers
and classmates should be educated about the childs condition. To form peer relationships,
socialization should be encouraged. Sports activities should be encouraged (e.g., Special
Olympics), not discouraged. Providing instructions on assertiveness is appropriate for
adolescence.
DIF: Cognitive Level: Analyzing REF: p. 766
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. What are supportive interventions that can assist an adolescent with a chronic illness to meet
developmental milestones? (Select all that apply.)
a. Encourage activities appropriate for age.
b. Avoid discussing planning for the future.
c. Provide instruction on interpersonal and coping skills.
d. Emphasize good appearance and wearing of stylish clothes.
e. Understand that the adolescent will not have the same sexual needs.
ANS: A, C, D
To achieve independence from family, instruction on interpersonal and coping skills should be
provided. To promote heterosexual relationships, activities appropriate for age should be
encouraged, and a good appearance and wearing of stylish clothes should be emphasized. Plans
for the future should be discussed, and the adolescent will have the same sexual needs as
adolescents without a chronic illness.
DIF: Cognitive Level: Analyzing REF: p. 767
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
MATCHING
Match the concepts related to children with special health care needs to their definitions.
a. Chronic illness
b. Congenital disability
c. Developmental disability
d. Impairment
e. Special needs
1. A loss or abnormality of structure or function
2. Any mental or physical disability that is manifested before the age of 18 years
3. A long-lasting or recurrent condition that interferes with daily functioning that persists for
more than 3 months
4. A disability that has existed since birth but may not be hereditary
5. A condition requiring assistance for disabilities that may be medical, mental, or psychological
