Pediatric Nursing The Critical Components of Nursing Care 1st Edition by Kathryn Rudd  – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Pediatric Nursing The Critical Components of Nursing Care 1st Edition by Kathryn Rudd  – Test Bank

 

Sample  Questions

 

Chapter 6: Theoretical Foundations of Growth and Development

 

 

 

Multiple Choice

 

 

 

  1. The nurse is beginning to administer the Denver II to a small child when his mother says, “Can you tell me again what this Denver II is?” The nurse’s best response is which of the following?
  2. “It’s a simple intelligence test for young children.”
  3. “It tells us what a child can do at a particular age.”
  4. “It determines a child’s visual acuity.”
  5. “It is a test to screen for hearing abnormalities.”

 

ANS: 2

Feedback
1. The test does not measure intelligence, but focuses on developmental milestones.
2. The test measures the level of development and compares to the standard.
3. The test focuses on cognitive, hearing, visual, and physical skills.
4. The test focuses on cognitive, hearing, visual, and physical skills.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Which of the following characteristics best describes the fine motor skills of a 5-month-old infant?
  2. Neat pincer grasp
  3. Strong grasp reflex
  4. Builds a tower of two cubes
  5. Able to grasp objects voluntarily

 

ANS: 4

Feedback
1. The child is too young for this skill.
2. The child is past this stage of fine motor skill.
3. The child is too young for this skill.
4. This is a normal response for a 5 month old.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Antonio is assessing an adolescent. Identify the top priority.
  2. Converse about peers
  3. Allow time to express feelings
  4. Use the same language as the adolescent
  5. Emphasize that confidentiality will be maintained

 

ANS: 2

Feedback
1. Conversing about peers is not a focus of the assessment.
2. The adolescent needs time to express feelings during the assessment.
3. Adolescents should be spoken to in the same manner as an adult.
4. Confidentiality cannot be maintained if the adolescent speaks of hurting himself/herself or others.

KEY: Content Area: Development | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A new mother is asking about when her baby daughter should be learning to sit. The nurse knows that a baby will sit at approximately which age?
  2. 8 months
  3. 4 months
  4. 5 months
  5. 1 year

 

ANS: 1

Feedback
1. Usually occurs at this age
2. Too early to sit up
3. Too early to sit alone
4. Should be sitting before this age

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a 2-and-one-half-month-old infant at the outpatient clinic. The nurse would anticipate that the baby should:
  2. Smile when presented with pleasurable stimuli.
  3. Cry at seeing a stranger’s face.
  4. Reach for the primary care giver.
  5. Hold a bottle.

 

ANS: 1

Feedback
1. An infant of this age should smile.
2. An infant at this age does not distinguish between stranger and caregiver.
3. An infant at this age is too young to reach for the caregiver.
4. An infant at this age is too young to hold a bottle.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The developmental task that a toddler between the ages of 15 to 30 months is likely to be struggling with is a sense of:
  2. Trust.
  3. Initiative.
  4. Autonomy.
  5. Intimacy.

 

ANS: 3

Feedback
1. The child is past this developmental milestone.
2. The child has yet to reach this stage.
3. The child will demonstrate this behavior.
4. The child has not reached this stage.

KEY: Content Area: Development | Integrated Processes: Teaching /Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Parents of a 2 year old are attempting to toilet train. The nurse has spoken to the family and should encourage which of the following to occur for successful toilet training?
  2. Anticipate that the bladder will be trained before the bowel.
  3. The child will respond more if the parents are encouraging.
  4. Having the child watch an older sibling use the toilet will cause confusion.
  5. The child must be forced to sit on the toilet when first learning.

 

ANS: 2

Feedback
1. Does not always occur in this manner
2. The more encouraging the parent, the higher the success rate.
3. Watching others use the toilet can help the child learn the behavior.
4. The child will resist potty training if forced.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The nurse is attempting to obtain a physical assessment of a 15-month-old child. The nurse knows that the most appropriate approach to performing the physical assessment includes all of the following except:
  2. Demonstrating the use of the blood pressure cuff on a teddy bear.
  3. Performing the most invasive assessments first.
  4. Letting the child exam the nurse first.
  5. Taking the blood pressure first, which will allow the child to ease into the full exam.

 

ANS: 4

Feedback
1. Demonstrating on an object lets the child see what will occur.
2. The invasive procedure will not alarm the child, so the vital signs will not rise quickly.
3. Letting the child examine the nurse allows the child to see what will occur.
4. Taking the blood pressure should not occur until after the heart rate and respiratory rate have normalized.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The purpose of the Tanner Stages is:
  2. To identify the five stages of sexual development in adolescents.
  3. To identify the cognitive stages of adolescents.
  4. To identify the five stages of sexual development for a school-age child.
  5. To identify the cognitive development of a school-age child.

 

ANS: 1

Feedback
1. Identification of sexual development in adolescents is the purpose of the Tanner Stages.
2. Cognitive stages are assessed through other theories.
3. Sexual development does not begin until adolescence, thus the age range is not appropriate.
4. Cognitive stages are assessed through other theories.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Which of the following statements regarding failure to thrive is true?
  2. Height or weight is less than 3% to 5% for age on more than one occasion.
  3. Failure to thrive is always caused by child abuse or poor parenting.
  4. Height or weight falling two major percentile lines on the NCHS growth charts is indicative of failure to thrive.
  5. Smoking and alcohol use during pregnancy are linked to failure to thrive.

 

ANS: 3

Feedback
1. Does not give a measurement of what 3% to 5% is based on.
2. Can have an organic cause
3. The NCHS growth charts give a developmental curve for tracking the child’s growth in order for the diagnosis to occur.
4. Failure to thrive occurs after birth.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The mother of a 3 year old with the diagnosis of failure to thrive asks what foods would be good to give her child for nutrition. Identify which foods are healthy choices for the child.
  2. Peanut butter and jelly sandwiches
  3. Chocolate milk
  4. Yogurt and bananas
  5. Chips and low fat dip

 

ANS: 3

Feedback
1. Contains a high level of sugar, which does not aid in growth
2. Contains a high level of sugar, which does not aid in growth
3. The protein from the yogurt and the vitamins/minerals in bananas will aid in a healthy growth pattern for the child.
4. Chips are high in carbohydrates and fat content, which do not aid in growth.

KEY: Content Area: Nutrition | Integrated Processes: Teaching | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A home health nurse is visiting an 18-month-old pediatric patient with the diagnosis of failure to thrive. A priority assessment for the child would be:
  2. Head circumference.
  3. Height and weight.
  4. Abdominal circumference.
  5. 1 and 2 should be documented.

 

ANS: 4

Feedback
1. Head circumference is a priority assessment to make sure the brain is growing at an adequate rate.
2. Height and weight are priority assessments to make sure the child is receiving good nutrition for optimal growth.
3. Does not indicate the growth pattern of a child
4. Head circumference is a priority assessment to make sure the brain is growing at an adequate rate. Height and weight is a priority assessment to make sure the child is receiving good nutrition for optimal growth.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The nurse is assessing a 2-month-old infant. The nurse knows when she sees the child move its head from side-to-side that the child has ___________ control.
  2. Proximodistal
  3. Cephalocaudal
  4. Differentiation
  5. None of the above are correct.

 

ANS: 1

Feedback
1. Movement is demonstrated in side-to-side motions.
2. Movement from head to toe is not demonstrated.
3. The infant is not demonstrating knowledge of the difference between moving the head from side-to-side and moving from head-to-toe.
4. One of the answers is correct.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The nurse is assessing a child who is 3 years old. The Babinski Reflex is assessed and noted to be present. The nurse knows that:
  2. This is a normal response to the test.
  3. This is an abnormal response to the test and should be further assessed.
  4. The reflex is abnormal, but the child will eventually grow out of it.
  5. This is normal and should be repeated on both feet.

 

ANS: 2

Feedback
1. This reflex should not be present in a child of this age.
2. This reflex should not be present after 2 years of life. It presents the need for an in-depth neurological exam.
3. Demonstration of this reflex at this age needs to be further assessed by a care provider.
4. This reflex should not be present at this age. If it is present in one foot, it will be present in the other.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A nursery nurse is assessing a newborn. A normal assessment finding is:
  2. The child lifting its head off of the mattress.
  3. Head lag is present.
  4. Holding hands in an open position.
  5. Placing a toy in the mouth.

 

ANS: 2

Feedback
1. A newborn does not have enough muscle control to lift his or her head off of a mattress.
2. Head lag is normal at this age.
3. At this age, a newborn will not hold their hands in an open position for long periods of time.
4. Placing a toy in the mouth does not occur for several months.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. During an assessment, the nurse notes the anterior fontanel of a 5 month old is open. This finding:
  2. Is abnormal, and the doctor should be immediately notified.
  3. Is abnormal at this age, and a head circumference should be done prior to calling the doctor.
  4. Is normal at this age.
  5. Is normal and should close by the age of two.

 

ANS: 3

Feedback
1. This is a normal finding, so the doctor does not need to be notified.
2. This is a normal finding.
3. The normal finding should be documented.
4. This is a normal finding, and the fontanel should close by the age of 18 months.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A mother is concerned that her 8-month-old child does not have any teeth. The best response from the nurse would be:
  2. “Teeth tend not to come in until around 18 months, so this is normal.”
  3. “I understand your concern about the lack of teeth. I will make sure the doctor addresses your concerns.”
  4. “This is nothing to worry about. Your child is still young, and the teeth will come in when they are ready.”
  5. “Normal tooth eruption occurs by the one year mark. Continue to watch your child, and report to us if teeth have not come in by then.”

 

ANS: 4

Feedback
1. Teeth come at a variety of ages in children.
2. The lack of teeth at this age is normal, and the mother should be reassured that teeth come in at a variety of ages.
3. Stating that there is “nothing to worry about” is not therapeutic communication by a nurse.
4. This answer identifies the mother’s concerns and educates her on when teeth eruption will usually begin.

KEY: Content Area: Assessment | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The nurse is assessing the parent-child interaction of a 6 month old and her teen father. The stage of development for the infant is demonstrated when:
  2. The child relaxes and drinks a bottle when in the father’s arms.
  3. The child cries and refuses to eat with her father.
  4. The child imitates the father’s actions.
  5. The child is able to hold the bottle by himself.

 

ANS: 1

Feedback
1. The child is demonstrating being in Piaget’s Sensorimotor Stage. The relationship is proven to be positive.
2. The child is demonstrating mistrust with the father when being fed.
3. The child is too young to imitate the actions of the father.
4. The child is too young to hold the bottle by himself, and this does not support an interactive environment with the father.

KEY: Content Area: Development | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The public health nurse is assessing children at the well-child clinic. The nurse is assessing the gross motor skills of a 3 year old. Identify which activity the nurse would expect the child to be successful with.
  2. Riding a bike
  3. Jumping rope
  4. Jumping off of the bottom stair step
  5. Walking backward heel to toe

 

ANS: 3

Feedback
1. A child does not reach this stage until after the age of four.
2. Jumping rope occurs during the school-age years.
3. The child is demonstrating appropriate gross motor skills for his/her age.
4. Walking backward is a skill seen in school-age children.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A school nurse is assessing the interaction of a kindergarten classroom. A normal finding of social interaction at this age would be:
  2. Parallel play.
  3. Identified sex-role interactions.
  4. Pretend play.
  5. 2 and 3 would be present in a kindergarten classroom.

 

ANS: 4

Feedback
1. Parallel play occurs with toddlers.
2. Kindergarten children are able to identify gender roles.
3. Kindergarten children are able to engage in imaginative play.
4. Kindergarten children are able to identify gender roles. Kindergarten children are able to engage in imaginative play.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. According to Piaget’s theory, a normal thought process for an 18 to 24-month-old child would be:
  2. A diaper means a diaper changing is going to occur.
  3. A rattle should go in the mouth.
  4. A loud noise means something bad is going to happen.
  5. A thumb is for sucking.

 

ANS: 1

Feedback
1. The child is able to relate objects to a task.
2. This would occur earlier in the child’s life.
3. The child is not old enough to process this information.
4. This would occur earlier in the child’s life.

KEY: Content Area: Development | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A school nurse is teaching a fifth-grade classroom about good eating habits. The nurse knows she should:
  2. Allow time for questions and for questions to be asked of the children.
  3. Ask the children questions.
  4. Demonstrate the eating habits, then allow for questions.
  5. Give a quiz at the end to see what the children have learned.

 

ANS: 1

Feedback
1. Children in this age group are inquisitive and can respond to more complex questions.
2. Reciprocity of communication can be done with this age bracket of students.
3. The children are past the age of needing demonstration to understand good eating habits.
4. A quiz is for older children to check for learning.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A school nurse is working with small groups of high school sophomores to discuss sexually transmitted diseases. The best approach to educate this age range would be:
  2. To lecture, then allow for a question and answer period.
  3. Having media and handouts to engage the students.
  4. Having media and letting the students create information that they feel is pertinent to understand the material.
  5. To provide information in handouts.

 

ANS: 3

Feedback
1. Lecturing may cause teens to not pay attention.
2. Media and handouts are effective, but need to be explained in order to be pertinent for understanding.
3. Letting students exercise creative understanding promotes comprehensive learning.
4. Handouts are not effective unless explained in a pertinent manner to the students.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The student nurse is assessing a 9 month old that has a history of parental neglect. The student notices the child sucks his thumb constantly. According to Freud’s theory, this child is in which stage?
  2. Id
  3. Ego
  4. Superego
  5. Freud’s theory is not applicable for this age range.

 

ANS: 2

Feedback
1. The child is focusing on calming himself, not on others doing this for him.
2. The infant is demonstrating the ego because the concentration is on soothing the self.
3. The superego is not addressed because the child is focusing on the self.
4. Freud’s theory is applicable for this age.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A 13-year-old girl is developing breast buds. She feels that her development is behind most of her friends. The nurse discusses changes that are going to occur during the genital stage and what to expect socially. Identify changes that would be pertinent to this age.
  2. Change in friendships
  3. Challenge to be independent from parents
  4. Struggle with identifying sexuality
  5. All of the above are likely to occur at this stage of development.

ANS: 4

Feedback
1. Friendships are likely to change as interests change during this age.
2. This age range challenges parents to seek new boundaries and exhibit independence.
3. Identifying one’s sexuality occurs during this time.
4. All are characteristics that are present during this age range.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. An 11 month old is being fed by his grandmother. The child appears to have high anxiety and does not feed well. The nurse understands that the child is exhibiting:
  2. Trust vs Mistrust.
  3. Autonomy vs Shame and Doubt.
  4. Initiative vs Guilt.
  5. Industry vs Inferiority.

 

ANS: 1

Feedback
1. The infant has not built a relationship with this grandmother and demonstrates mistrust.
2. The child is not independently feeding.
3. The child is too young to exhibit guilt for his/her actions.
4. The child is too young to exhibit industry because of the lack of physical maturity.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a family of five. The nurse knows that the toddler is developing appropriately when the mother states:
  2. “I can’t get her to use the potty when I ask. As soon as I put a diaper back on, she uses it instead.”
  3. “All she wants us to do is feed her.”
  4. “She is always going up to strangers and talking to them.”
  5. “She is very conscientious with her siblings.”

 

ANS: 1

Feedback
1. The child is demonstrating independence. This is a normal finding with a toddler.
2. A toddler should be beyond this state.
3. A toddler demonstrates mistrust toward unfamiliar people.
4. A toddler does not have the cognitive ability for this and is still focused on the self.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The nurse is working with a teen boy who is contemplating having sex with his girlfriend. The nurse knows the teen is struggling with which developmental stage of Eriksons’s theory?
  2. Industry vs Inferiority
  3. Autonomy vs Shame and Doubt
  4. Trust vs Mistrust
  5. Identity vs Role Confusion

 

ANS: 4

 

Feedback
1. This stage occurs earlier in life.
2. The teen is beyond this stage.
3. The teen is beyond this stage.
4. The teen is attempting to identify with his age and the roles that he is supposed to have in a relationship.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Why is it important to provide education about motor vehicle safety to teens?
  2. Because this age range makes poor decisions based on lack of experience
  3. Because this age range tends to believe nothing will happen to them
  4. Because this age range receives a driver’s license
  5. Because this age range should be as responsible as adults

 

ANS: 2

Feedback
1. Teens do not feel poor decisions are being made.
2. Teens demonstrate a sense of freedom and independence that makes them believe nothing will cause them harm.
3. Receiving a driver’s license requires safety, but is not the main reason for teens to have motor vehicle safety education.
4. A teenage brain does not have the capability of understanding circumstances like an adult.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A nursing student is studying Kohlberg’s social-moral development. He knows that a child that attempts to do well on a spelling test for approval is in which stage?
  2. Reward and punishment
  3. Stage three
  4. Stage six
  5. Post-conventional Morality

 

ANS: 2

Feedback
1. A child does not link a reward for doing well in Kohlberg’s theory at this stage.
2. This stage identifies the success of a child as related to approval from adults.
3. A child does not link a reward for doing well in Kohlberg’s theory at this stage.
4. A child does not link a reward for doing well in Kohlberg’s theory at this stage.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. An 8-year-old boy, who was adopted, has a history of neglect and physical abuse. After living in the adoptive home for one year, the child is exhibiting similar speech patterns as the adoptive father. This is knows as:
  2. Nurture.
  3. Nature.
  4. Moral development.
  5. Cognitive development.

 

ANS: 1

Feedback
1. The child is in an environment that is supportive, and the child is demonstrating positive behavior patterns.
2. The child was not born with the speech patterns of the adoptive father.
3. The child may be developing moral values, but the speech patterns are a mimic of positive behavior.
4. The child may be developing cognitively, but the speech pattern is a mimic of positive behavior.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Identify the family type that has a father, daughter, and stepmother:
  2. Blended.
  3. Nuclear.
  4. Traditional Nuclear family.
  5. Bi-nuclear family.

 

ANS: 1

Feedback
1. A blended family has a stepparent.
2. The family does not consist of all the parents being biological to the child.
3. The family does not have a grandparent living in the home.
4. The home does not have extended family of either parent.

KEY: Content Area: Family Structure | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity| Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a child who appears to be very active, highly anxious, and lacks attention to detail. The nurse asks the child to sit still for the taking of the heart rate. If using Bandura’s theory, the nurse will need to:
  2. Attempt to do the assessment on someone else first so the child can watch and learn.
  3. Take the heart rate as quickly as possible.
  4. Observe the child’s activity level and not document the heart rate.
  5. Allow the child to be active and discuss what a heart rate means.

 

ANS: 1

Feedback
1. Demonstration allows the child to decrease his/her anxiety level.
2. Bandura’s approach is to calm and reduce stress for the child.
3. The heart rate is required and allowing the child to continue playing will not decrease anxiety and activity level.
4. Teaching the child about heart rate is important, but until the child is focused, the teaching will not be successful.

KEY: Content Area: Development | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A mother has given birth to her baby at 28 week’s gestation. The nurse knows that a premature birth:
  2. Causes future assessments to be based on the adjust age, not the chronological age.
  3. Does not cause a delay in growth and development.
  4. Occurs rarely and will not affect future assessments.
  5. Will reach developmental milestones at the same time as other full-term newborns.

 

ANS: 1

Feedback
1. An age adjustment must be done to adequately assess the development of the infant.
2. A delay in growth and development occurs because the brain’s synapses are not fully developed at 28 week’s gestation.
3. Future assessments will be impacted because of the lack of brain development at 28 week’s gestation.
4. A delay in growth and development occurs because the brain’s synapses are not fully developed at 28 week’s gestation.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. At a well-baby checkup, the nurse is assessing a former 32-week, premature infant. The chronological age of the infant is 6 months, so the nurse knows that during the assessment, the infant should be meeting the milestones of a(n):
  2. 8 month old.
  3. 4 month old.
  4. 6 month old.
  5. 3 month old.

 

ANS: 2

Feedback
1. Too old
2. Correct
3. Needs adjustment to the age due to prematurity
4. Too young

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A home care nurse witnesses a mother yelling at her 2 year old to quit crying because it gives everyone a headache. The home care nurse should:
  2. Make sure the child is safe, remove the mother from the situation, and contact social services and the police for help.
  3. Ask the mother to stop yelling because a 2 year old cannot understand that crying is no good.
  4. Explain to the mother that a 2 year old needs to cry to be understood.
  5. Contact the police to investigate for child abuse.

 

ANS: 1

Feedback
1. The safety of the child is the most important factor. Removing the child and getting help for the mother are important in maintaining the child’s safety.
2. Speaking to the mother at this point may work, but the nurse needs to be concerned for the child’s safety. Further abuse may occur when no one else is present.
3. Speaking to the mother at this point may work, but the nurse needs to be concerned for the child’s safety. Further abuse may occur when no one else is present.
4. The mother needs interventions to help learn to cope with the situation. Only using law enforcement does not help the mother learn parenting techniques.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A nurse is reviewing the results of a lead test with a teen mother. The mother asks how the child was exposed to lead. The best response would be:
  2. “Lead is in the everyday environment. Some people are more susceptible than others.”
  3. “Lead is in many of the foods we eat, so it is important to eat fresh vegetables and fruits because these foods have a lower lead level.”
  4. “Lead can be found in the paint within your house or on some old toys that had lead-based paint.”
  5. “You need to make sure that your child is kept away from lead because it can cause brain damage.”

 

ANS: 3

Feedback
1. Lead poisoning can happen to anyone.
2. Lead is mostly found in objects that cannot be consumed.
3. Lead-based paint causes the highest number of lead exposure.
4. Lead toxicity can cause brain damage, but the most important point is to teach the parent where lead can be found.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. Sleep deprivation in a child can lead to:
  2. Poor school performance.
  3. Hyperactivity.
  4. Irritability.
  5. All of the above.

 

ANS: 4

Feedback
1. Lack of sleep can cause inattentiveness in the classroom. This is not the only correct answer.
2. Lack of sleep can cause the child to be more active. This is not the only correct answer.
3. Lack of sleep can cause the child to be unable to tolerate certain situations. This is not the only correct answer.
4. All of the choices are correct answers.

KEY: Content Area: Sleep Patterns | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. When assessing with Maslow’s Hierarchy of Need, the nurse knows that self-actualization can only occur if:
  2. All the other levels have been met.
  3. The first stage of the needs chart is met.
  4. Parental involvement is present.
  5. The child has a certain level of self-esteem.

 

ANS: 1

Feedback
1. All levels must be met to achieve self-actualization.
2. Self- actualization is the final stage of the hierarchy.
3. A person must reach this level with people outside of their family.
4. A child has a level of self-esteem no matter what the situation.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. A safe environment for a school-aged child would include:
  2. Dressers being pulled away from a wall.
  3. A helmet when rollerblading.
  4. A safety lock on a cupboard with cleaning supplies.
  5. All are safety issues for a school-aged child

ANS: 4

 

Feedback
1. Positioning the dresser away from the wall allows for less of a chance for tipping, but this is not the only correct answer.
2. A helmet is needed for any activity with wheels, but this is not the only correct answer.
3. A safety lock is needed to keep hazardous materials out of reach, but this is not the only correct answer.
4. Correct. All choices are safety issues for children.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

  1. The school nurse is discussing safety hazards with a group of parents. The nurse states that it is important to:
  2. Lock everything you do not want your child to get to up in a safe place.
  3. To place the poison control number and emergency numbers near a phone, or program it into your cell phone.
  4. Remind a child to ride on the left side of the road toward traffic when on a bike.
  5. Allow a child to use the stove once they are five feet tall.

 

ANS: 2

Feedback
1. A school-age child can unlock cupboards.
2. Having easy access to emergency numbers will aid in emergency situations.
3. The child should ride on the right side of the road with traffic on a bike.
4. Height does not influence whether or not a child should use a stove.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

 

 

 

Multiple Response

 

 

 

  1. A nurse at a teen outreach center for pregnant mothers is discussing dental care with patients. Pertinent information for the nurse to teach about would be: (Select all that apply.)
  2. Cleaning the infant’s teeth with cool, wet washcloths at least every day.
  3. Bottles can be given in order for the infant to fall asleep and will not cause damage to the teeth.
  4. Juice should not be provided because it increases tooth decay.
  5. Providing teething rings can help reduce the pain of teething.
  6. Brushing of teeth should only occur every few days.

 

ANS: 1, 3, 4

Feedback
1. A wet washcloth is gentle enough for an infant’s teeth.
2. Bottles at bedtime increase the risk of dental decay in infants.
3. Juice can cause tooth decay.
4. Teething rings can help reduce pain.
5. A brush may be too harsh for an infant’s teeth.

KEY: Content Area: Dental Care | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Response

 

 

 

  1. The school nurse is helping in a classroom of 7 and 8 year olds on a rainy day. The nurse knows which types of games would be fun for this age range? Select all that apply.
  2. Playing a board game
  3. Playing a video game
  4. Playing jump rope
  5. Making crafts
  6. Making a friendship bracelet

 

ANS: 1, 4, 5

Feedback
1. A child of this age understands and participates in board games.
2. A video game can be overwhelming for a child of this age range.
3. Jumping rope may not be an acquired skill at this age and is not a game to be played in the classroom due to safety concerns.
4. Making crafts is appropriate for this age.
5. Friendships become important at this age and making the bracelets is appropriate.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Response

 

 

 

  1. During the preoperational stage, a 6 year old would be expected to: (Select all that apply.)
  2. Gather more language skills.
  3. Use crayons to draw pictures about being mad.
  4. Think real things are fantasy.
  5. Understand time.
  6. Remember events from the recent past.

 

ANS: 1, 2, 5

Feedback
1. The child is learning new words and meanings rapidly at this time.
2. The child is learning to channel emotions into drawings.
3. The child is past this point and realizes what is real.
4. The child is too young to begin to understand time.
5. The child is able to remember events that have occurred recently.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6  | Type: Multiple Response

 

 

 

  1. Factors that can impact the intrauterine growth of a fetus are: (Select all that apply.)
  2. The mother’s nutrition.
  3. Maternal smoking.
  4. The mother’s employment.
  5. The father’s employment.
  6. Prescription drugs.

 

ANS: 1, 2, 5

Feedback
1. The mother’s calorie, vitamin, and mineral intake all influence the fetus’s growth.
2. Smoking inhibits the growth of the fetus due to lack of oxygen.
3. Employment is not a factor in growth.
4. Employment is not a factor in growth.
5. Certain medications decrease nutrition and oxygen to the fetus during development.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Response

 

 

 

True/False

 

 

 

  1. Separation anxiety is a normal development in a preschooler.

 

ANS: F

Feedback
1. Separation anxiety is seen in toddlers. Preschoolers fear the dark, being left alone, ghosts, and mutilation.
2. Separation anxiety is seen in toddlers. Preschoolers fear the dark, being left alone, ghosts, and mutilation.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: True/False

Chapter 7: Newborn and Infants

 

 

 

Multiple Choice

 

 

 

  1. A mother brings her 9 month infant in for a routine visit. What milestone would be appropriate for the doctor to ask if the infant is meeting?
  2. Walking
  3. Speaking in two word phrases
  4. Rolls back to stomach and stomach to back
  5. All of the above

ANS: 3

 

  Feedback
1. Between 10–12 months of age, an infant can walk
2. Between 14–16 months of age, an infant can speak two word phrases
3. Between 6 and 9 months of age, an infant can roll from back to stomach and stomach to back.
4. Many infants will not be walking at this age. It is too soon for word phrases to be developed.  The child should be rolling.

KEY: Content Area: Growth and Development| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A 5 day old infant comes in for a newborn checkup. On assessment of the newborn, you note that the skin is jaundice in color. The anterior fontanel is slightly sunken. Per mom, the infant has only had 2 diapers today. The infant is strictly breastfed and this is mom’s first child. She states baby is having trouble latching on. A bilirubin level is sent and comes back at 18. You identify this newborn to be dehydrated and is most likely to have breast milk jaundice. Which nursing intervention(s) will be required for this baby?
  2. Phototherapy
  3. Providing support and education for the lactating mother
  4. Strict monitoring of intake and output
  5. All of the above

ANS 4

 

Feedback
1. Phototherapy will be required to help decrease the level of bilirubin.
2. It is important to provide the mother with support and education and offer a lactation specialist.
3. This infant is dehydrated so it will be necessary to monitor strict I & O’s.
4. Breast Milk Jaundice occurs in 1–2% of breastfed babies. At early onset there are poor feeding patterns and bilirubin levels may spike to 19. It is important to provide the mother with support and education and offer a lactation specialist. This infant is dehydrated so it will be necessary to monitor strict I & O’s.  Phototherapy will be required to help decrease the level of bilirubin.

KEY: Content Area: Hyperbilirubinemia| Integrated Processes: Nursing Process | Client Need: Physiological integrity | Cognitive Level: Application| REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. Apgar scores measure heart rate, respiratory rate, reflex irritability, color and :
  2. Rigidity
  3. Muscle tone
  4. Birth weight
  5. Capillary refill

ANS: 2

Feedback
1. Not assessed  for the APGAR score
2. Apgar scores measure 5 areas: respiratory rate, heart rate, muscle tone, color and reflex irritability. The higher score indicates adequate adaptation. Scores are done at 1 minute and 5 minutes after birth.
3. Not assessed for the APGAR score
4. Not assessed the APGAR score

KEY: Content Area: Physiology | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A mother on the postpartum unit asked to have her infant back from the nursery so that she can breastfeed. The nurse brings the newborn to the room and hands the baby to the mother. She asks the mother to let her know how long the baby feeds. What vital step did the nurse forget to take before giving the baby to the mother?
  2. The nurse should have made sure that the baby was latching correctly
  3. The nurse should have identified the baby’s ID band with the mother’s
  4. The nurse should have the mother speak with a lactation consultant
  5. The nurse should have asked the mother how long she planned to feed

ANS: 2

Feedback
1. It is vital that ID bands are checked with baby and mother before leaving the infant.
2. It is vital that ID bands are checked with baby and mother before leaving the infant.
3. Safety of the baby is the first priority
4. Safety of the baby is the first priority

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. Excessive heat loss results in which of these?
  2. RDS
  3. Depletion of glucose levels
  4. Jaundice
  5. Increase in surfactant levels

ANS: 2

Feedback
1. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels
2. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels
3. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels
4. Surfactant levels decrease

KEY: Content Area: Physiology| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A mother has just delivered her new baby a few hours ago. She asks the nurse if she can bathe the baby because he has blood on him. The best response from the nurse would be.
  2. “Sure, let me get you some soap and washcloths”
  3. “Why don’t you get some rest, there will be lots of time for bathing”
  4. “It’s important that we not bathe the baby too soon after birth. Let’s wait till later in the day.”
  5. “Sure, but why don’t you feed the baby”

ANS: 3

Feedback
1. A nursing intervention to prevent hypothermia is to delay the first bath until the infant has regulated and stabilized core body temperature.
2. Avoids the mother’s question and an explanation should occur
3. A nursing intervention to prevent hypothermia is to delay the first bath until the infant has regulated and stabilized core body temperature.
4. Avoids the mother’s question and an explanation should occur

KEY: Content Area: Physiological| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A 4 week old infant is brought to the ED. Mom states that the baby hasn’t been eating well and has had decreased diapers for 2 days. The baby has been sleeping more and has been hard to wake up. On assessment, you find that the baby is difficult to arouse, is hypotonic and temperature is 35.4 rectally. What is an important lab value to check? Choose the best answer.
  2. Complete metabolic panel
  3. Liver panel
  4. Blood glucose
  5. PTT

ANS: 3

Feedback
1. Not the first choice due to the length of time to have results for  a CPM
2. The signs and symptoms do not indicate the need for a liver panel
3. Lethargy, poor feeding, hypotonic and temperature instability are all signs of hypoglycemia
4. The sign and symptoms do not indicate a need for a PTT

KEY: Content Area: Physiology| Integrated Processes: Nursing Process | Client Need: Physiology Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A pregnant woman with a history of a clotting disorder is required to self-administer heparin during her pregnancy. After delivery, the infant will be at greater risk for:
  2. Low blood sugar
  3. Decrease Vitamin K
  4. Increased Vitamin K
  5. High blood sugar

ANS: 2

Feedback
1. Anticoagulants do not effect blood sugar
2. An infant of a mother who is treated with anticoagulants are at risk for decreased vitamin K levels
3. Anticoagulants have the opposite effect on vitamin K
4. Anticoagulants do not effect blood sugar

KEY: Content Area: Pharmacology| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A part of injury prevention is making and keeping infant appointments. The required checkups and vaccinations are at:
  2. 3 months, 6 months, 9 months
  3. 2 months, 4 months, 6 months and 1 year
  4. 2 months, 4 months, 6 month, 9 months and 1 year
  5. 2 months, 4 months, 9 months and 1 year

ANS: 3

 

Feedback
1. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.
2. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.
3. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.
4. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

KEY: Content Area: Growth| Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. You are taking care of an infant who was admitted with dehydration. His weight is 6kg. You have been watching his I & O’s. What would you expect the infant’s urinary output to be in order to maintain adequate hydration?
  2. 0.5–2 ml/kg/hr
  3. 0.5–2.5 ml/kg/hr
  4. 1–3 ml/kg/hr
  5. As long as he is having wet diapers it doesn’t matter

ANS: 3

Feedback
1. Urine output is not in normal range
2. Urine output is not in normal range
3. Urine output for the newborn/infant should be 1–3 cc/kg/hr, in the hospital, to maintain adequate fluid maintenance
4. Measuring I & O is important to assess kidney function in a dehydrated patient

KEY: Content Area: Renal/Urinary| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge |  REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A mother brings her newborn daughter to the ER with concerns that she is having vaginal bleeding. You know this is normal and called what?
  2. Pseudomenstruation
  3. Milia
  4. Vernix caseosa
  5. Toxicum

ANS: 1

 

Feedback
1. Pseudomenstruation is thin white or blood tinged mucus that may be present due to maternal withdrawal of hormones.
2. Incorrect term
3. Incorrect term
4. Incorrect term

KEY: Content Area: Physical Assessment| Integrated Processes: Nursing Process | Client Need: Physiological Assessment | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. While interviewing the mother of an infant, you note that the mother gets frustrated as she explains that her baby has been up all night crying at least 3 times a week for the last 2 weeks. She states that she has tried everything and feels hopeless. What would be the BEST response from you as the nurse?
  2. “Believe me, I know. I have a newborn too.”
  3. “Have you tried warm milk?”
  4. “It’s ok to be frustrated and feel overwhelmed.”
  5. “You are doing nothing wrong. This can be a common occurrence in infants and you should not feel guilty.”

ANS: 4

Feedback
1.  It is important that education is provided to the mother or caregiver so that they know the irritability is not a reflection of their parenting skills.
2. Infants do not have the enzyme to absorb milk thus would cause more stomach upset
3. Acknowledgement of the mother’s feelings is important. Mother needs educated about Infant Colic.
4. The mother is describing Infant Colic. This can be very frustrating for mothers. They can feel helpless, hopeless and like a terrible mother. It is important that education is provided to the mother or caregiver so that they know the irritability is not a reflection of their parenting skills.

KEY: Content Area: Physiological| Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. The benefits of breast-feeding are
  2. Decreased risk of obesity
  3. Convenience
  4. Promotes positive bonding with infant and mother
  5. All of the above

ANS: 4

Feedback
1. Improves nutritional outcomes for the infant
2. Breastfeeding requires no bottle preparation
3. Positive bonding occurs in breastfeeding
4. Breastfeeding is the optimal method of feeding because it provides all nutrients, minerals, and vitamins needed.  There is no bottle required and baby and mother can bond.

KEY: Content Area: Nutrition| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. The AAP’s recommendations for length of breastfeeding is
  2. 6 months
  3. 6 months with the first child
  4. 1 year
  5. 9 month

ANS: 3

  Feedback
1. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.
2. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.
3. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.
4. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.

KEY: Content Area: Nutrition| Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. When interviewing the mother of an infant the nurse asks some questions about how the baby is fed. What statement tells you that the mother will need further education?
  2. “I always use the ready to feed because it is easier.”
  3. “I burp Junior at the end of his bottle.”
  4. “I rock him while he feeds.”
  5. “I just bought this great bottle warmer.”

ANS: 2

Feedback
1. The mother has found a feeding technique that fits her lifestyle and gives adequate nutrition to the infant.
2. It is important to burp the infant frequently (about every ounce) to prevent emesis d/t swallowed air.
3. Rocking can be a comfort measure for feeding
4. The mother understands about warming the bottle prior to feeding

KEY: Content Area: Nutrition| Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. The physician is discussing feeding habits and schedule with a mother of a 4 month old. Which statement from the mother would warrant the need for further teaching and education?
  2. “I just recently introduced table foods.”
  3. “I feed him every 3 hours.”
  4. “I don’t wake him for feeds throughout the night if he will sleep.”
  5. All of the above

ANS: 1

Feedback
1. An infant is ready for solid foods around 6 months of age. All foods should be placed on a spoon not in the bottle. Baby rice cereal is usually indicated for the first solid food.
2. Feeding every three hours during the day is adequate for this age
3. A four month old does not need to be awakened during the night for feedings
4. One statement is not applicable

KEY: Content Area: | Integrated Processes: Teaching/Learning| Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. Research has shown that endogenous opioid pathways that result in calming and pain-relieving effects are activated by:
  2. Tylenol
  3. Kangaroo care
  4. Sucrose
  5. Nonnutritive sucking
  6. Choice 3 and 4

ANS: 5

Feedback
1. Does not produce an endogenous response
2. While this comforts a neonate it does not have an endogenous opioid pathway
3. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and pain-relieving effects.
4. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and pain-relieving effects.
5. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and pain-relieving effects.

KEY: Content Area: Comfort| Integrated Processes: Caring| Client Need: Physiological Integrity | Cognitive Level: Application |  REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A mother of a newborn baby boy is unsure of whether or not to have her son circumcised. She asks the nurse what is recommended by the AAP. The nurse tells her that as of 1999, the AAP’s recommendation is:
  2. They highly recommend routine circumcisions
  3. They strongly recommend circumcision only if the parents are worried about infections
  4. They have no current stance
  5. They do not recommend routine circumcisions

ANS: 4

 

Feedback
1. The current position statement issued in 1999 does not recommend routine circumcision of the newborn.
2.  The infection rate does not change with a circumcision
3. The current position statement issued in 1999 does not recommend routine circumcision of the newborn.
4. The current position statement issued in 1999 does not recommend routine circumcision of the newborn.

KEY: Content Area: Wellness| Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | Ref: Chapter 7 | Type: Multiple Choice

 

 

 

  1. Which of the following interfere with the absorption of some medications in neonates and infants?
  2. Immature kidney function
  3. Absence of hydrochloric acid
  4. Less pancreatic enzymes
  5. All of the above

 

Feedback
1. Immature kidney function influences absorption
2. The lack of hydrochloric acid influences absorption
3. A neonate has less pancreatic enzymes
4. In neonates there is an absence of hydrochloric acid, and in infants, less pancreatic enzymes and immature kidney function which may interfere with absorption of some medications.

KEY: Content Area: Pharmacology| Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. The nurse is doing discharge teaching and instructs the parents to notify their healthcare provider with any of these important concerns regarding the newborn/infant.
  2. Temperature over 99.3 degrees Fahrenheit
  3. Vomiting
  4. Decreased wet diapers
  5. All of the above

ANS: 4

Feedback
1. A temperature greater than 99.3 degrees Fahrenheit, especially in a newborn, may be a sign of sepsis
2. Vomiting and decreased wet diapers can be a sign on dehydration
3. Vomiting and decreased wet diapers can be a sign on dehydration
4. A temperature greater than 99.3 degrees Fahrenheit, especially in a newborn, may be a sign of sepsis. Vomiting and decreased wet diapers can be a sign on dehydration. Infants and children have less reserve than adults and can become dehydrated quickly.

KEY: Content Area: Education| Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. The nurse is assessing pain on a 1 year old. What is the appropriate pain scale to use?
  2. NIPS
  3. FACES
  4. FLACC
  5. CHOPS

ANS: 3

Feedback
1. Not recommended for this age range
2. Not recommended for this age range
3. FLACC or the Face, Legs, Activity, Cry, Consolability scale is a measurement used to assess pain for children between the ages of 2 months-7 years or until the child is able to understand the concept of pain (then the FACES scale can be used).
4. Not recommended for this age range

KEY: Content Area: Pain| Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. On assessment of a 6 month old infant you note that the anterior fontanel is flat and soft and the posterior fontanel is no longer palpable. This is an appropriate finding because the posterior fontanel closes at:
  2. 6 months
  3. 4 months
  4. 2 months
  5. 5 months

ANS: 4

Feedback
1. The posterior fontanel is triangular in shape, 1­–2 cm and closes in the 2nd month.
2. The posterior fontanel is triangular in shape, 1–2 cm and closes in the 2nd month.
3. The posterior fontanel is triangular in shape, 1–2 cm and closes in the 2nd month.
4.  The posterior fontanel is triangular in shape, 1–2 cm and closes in the 2nd month.

KEY: Content Area: Growth| Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. A mother is concerned that every time she leaves the hospital room to take a break, her 8 month old cries. The nurse explains to the mother that this is normal behavior and that her infant is experiencing
  2. Safety issues
  3. Separation anxiety
  4. Irritability
  5. Colic

ANS: 2

Feedback
1. The child is too young to know about safety issues
2. Between the ages of 6 and 9 months, infants suffer from separation anxiety and can be sensitive to caregiver cues
3. The child only cries when the mother leaves, if irritable the child would cry more often
4. The child is past the age of colic occurring

KEY: Content Area: Development| Integrated Processes: Teaching/Learning| Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. Highlights in education for promoting safety in infants involves
  2. Burns and car seat safety
  3. Preventing choking and poisoning
  4. Safe Sleep
  5. All the above

ANS: 4

Feedback
1. These 5 topics are important for parents and caregivers to be aware of when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their child’s growth.
2. These 5 topics are important for parents and caregivers to be aware of when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their child’s growth.
3. These 5 topics are important for parents and caregivers to be aware of when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their child’s growth.
4. These 5 topics are important for parents and caregivers to be aware of when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their child’s growth.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 7 | Type: Multiple Choice

 

 

 

  1. During her interview with the mother, the nurse asks sleep related questions. She finds out that the infant is placed on her belly for sleep. The nurse beings to explain safe sleep measures and includes:
  2. Placing the infant in a side lying position after feeds
  3. Placing the infant propped on a pillow for comfort
  4. Placing the infant on her belly for only naps
  5. Placing the infant on her back in a bare naked crib

ANS: 4

Feedback
1. AAP recommends that all infants be placed on their backs for sleep in a bare naked crib. This means just a fitted sheet, no bumpers, blankets, pillows or toys. These are all suffocation hazards. The infant should not be tightly swaddled and arms should be free. Tightly swaddled infants are at risk for overheating and at greater risk for SIDS.
2. A pillow can increase the chance for suffocation
3. The infant should only be placed on her belly when awake and supervised
4. AAP recommends that all infants be placed on their backs for sleep in a bare naked crib. This means just a fitted sheet, no bumpers, blankets, pillows or toys. These are all suffocation hazards. The infant should not be tightly swaddled and arms should be free. Tightly swaddled infants are at risk for overheating and at greater risk for SIDS.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Health Promotion an d Maintenance | Cognitive Level: Application | REF: Chapter 7 | Type: Multiple Choice

Chapter 11: Respiratory Disorders

 

 

 

Multiple Choice

 

 

 

  1. An 8-year-old child with a history of cystic fibrosis has a chest that is larger than normal. This type of feature on a child is known as:
  2. A concaved chest.
  3. A barrel chest.
  4. An asymmetrical chest.
  5. All of the above are correct.

 

ANS: 2

Feedback
1. The chest does not bow inward in a child with cystic fibrosis.
2. A barrel chest is common in a child with cystic fibrosis because of the air trapping that occurs within the lungs.
3. The chest is symmetrical in appearance with cystic fibrosis.
4. Not all of the options are correct.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When a nurse enters the room of a child with chronic lung disease, she notes that the child is sitting in a tripod position. Identify the reason for this positioning by the child.
  2. The child feels more comfortable playing in this position.
  3. The child is attempting to have a bowel movement.
  4. The child is having trouble breathing, and the position is comfortable
  5. The child is in a resting position after walking in the hallway.

 

ANS: 3

Feedback
1. The child may feel comfortable in this position, but it is not the primary reason for the positioning.
2. A child will squat on their haunches when having a bowel movement.
3. The tripod position enables the diaphragm to fully expand and attempt to get as much oxygen into the body as possible.
4. A child who is resting will sit or lie down on the bed.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When a child exhibits difficulty breathing, the best positioning would be:
  2. Having the head of the bed at 45 degrees.
  3. Placing the child in a 90 degree angle on the parent’s lap.
  4. Placing the child in a side lying position.
  5. Having the child sit in a chair.

 

ANS: 1

Feedback
1. Positioning the head of the bed slightly elevated will take weight off of the diaphragm and allow for full chest expansion.
2. Placing the child at a 90 degree angle will put too much pressure on the diaphragm, thus causing the shortness of breath to continue.
3. A side lying position does not help to support the diaphragm or aid in relieving the shortness of breath.
4. Sitting in a chair will place more stress on the accessory muscles, thus the child will continue to have shortness of breath.

KEY: Content Area: Respiratory | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A father is concerned that his newborn baby girl is cold because her hands are blue. The nurse explains to the father that:
  2. This is a sign of respiratory distress, and the baby needs to return to the nursery.
  3. Most newborns have trouble regulating their body temperature.
  4. This is acrocyanosis and should go away within 48 hours after her birth.
  5. This is bruising the baby received during the birth process.

 

ANS: 3

Feedback
1. Respiratory distress would be noted if the newborn had circumoral cyanosis.
2. Healthy newborns are able to regulate their body temperature soon after birth if dressed for the environment.
3. The newborn is exhibiting acrocyanosis. It is not a sign of coldness.
4. Bruising usually does not occur on the hands.

KEY: Content Area: Assessment | Integrated Processes: Teaching/Documentation | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is attempting to assess the skin color of a child with dark skin. The nurse knows the best place to assess the child’s skin color is:
  2. The nailbeds.
  3. Inside the mouth in the cheek area.
  4. The eyes.
  5. On the chest.

 

ANS: 2

Feedback
1. The nailbeds should be used to assess capillary refill.
2. A pen light can be used to examine the inside of a child’s mouth in the cheek area for color.
3. The eyes can indicate jaundice, but not any other type of color changes.
4. Capillary refill can be assessed on the chest since the oral mucous membranes are more accurate.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child with respiratory distress can experience dehydration because:
  2. The child is not drinking enough fluids.
  3. The body requires an increased amount of fluids when sick.
  4. The child is retaining water in the kidneys since the body is using all the oxygen in the lungs.
  5. Mouth breathing occurs when in distress, so the child is losing hydration.

 

ANS: 4

Feedback
1. Respiratory distress causes dehydration issues.
2. Fluids are required to keep mucous membranes and secretions moist, but are not the reason for dehydration.
3. Water is not retained in the kidneys with respiratory difficulties.
4. Children are known to be mouth breathers during respiratory distress situations, thus increasing their risk for dehydration due to the lack of moist mucous membranes.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When performing an assessment on an 8-year-old boy who is hospitalized for pneumonia, the nurse would anticipate what type of lung sounds?
  2. Crackles
  3. Stridor
  4. Normal
  5. Wheezes

 

ANS: 1

Feedback
1. Fluid is built up in the lungs because of the infection, causing crackles to be heard.
2. Stridor is common in children with larynx issues, not pneumonia.
3. When fluid builds up in the lungs, it will cause the lung’s sounds to be abnormal with a diagnosis of pneumonia.
4. A child will have wheezes if the airway is constricted, not full of fluid.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 5-year-old child has been admitted for complications related to asthma. When the nurse auscultates the child’s lungs, she would anticipate hearing:
  2. Wheezes because the bronchioles have been restricted.
  3. Rhonchi because of thick secretions from the flare-up.
  4. Crackles because there is fluid in the alveoli.
  5. All of the above may be heard.

 

ANS: 1

Feedback
1. Asthma constricts the airway and alveoli in children, causing wheezing to be heard when in auscultation.
2. Rhonchi usually will clear with a cough. A child with an asthma exacerbation will not stop the sound after coughing.
3. Asthma causes the narrowing of airways. Crackles occur only when fluid is present.
4. The airway and alveoli constriction causes wheezing.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When assessing a 12-year-old girl with the diagnosis of pneumonia, the nurse performs percussion. The lower left lobe is noted to have a dull sound. What should the nurse do next?
  2. Call the doctor with the assessment.
  3. Check the orders and start chest physiotherapy.
  4. Palpate the chest to check for tactile fremitus.
  5. Place the child on oxygen.

 

ANS: 4

Feedback
1. The doctor will need to be called after oxygen is applied because the first priority is to maintain oxygen saturation in order to prevent further respiratory distress.
2. The child needs immediate intervention.
3. Tactile fremitus will be increased due to the pneumonia.
4. The assessment indicates that the child has a lower lobe that is not expanding and needs oxygen supplementation in order to maintain saturation levels.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child has the following ABG results:

pH: 7.38

pCO2: 52.6

HCO3: 32.5

The nurse interprets these results as:

  1. Compensated Respiratory Acidosis.
  2. Uncompensated Respiratory Alkalosis.
  3. Compensated Respiratory Alkalosis.
  4. Uncompensated Respiratory Acidosis.

 

ANS: 1

Feedback
1. The pH is on the low end, creating a more acidotic state along with the CO2 in an acidotic state, thus indicating the respiratory acidosis. The HCO3 is alkalotic, creating compensation.
2. The pH and the CO2 are acidotic and the HCO3 is alkalotic, creating compensation.
3. The pH and CO2 are in acidotic states, not alkalotic states.
4. Compensation has occurred because of the HCO3 being alkalotic.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child’s ABG results are:

pH: 7.14

pCO2: 24.6

HCO3: 8.0

The nurse interprets these results as:

  1. Normal ABG.
  2. Partially Compensated Metabolic Acidosis.
  3. Uncompensated Metabolic Acidosis.
  4. Uncompensated Respiratory Acidosis.

 

ANS: 2

Feedback
1. The pH is acidotic, the CO2 is alkalotic, and the HCO3 is acidotic. Because the pH and the HCO3 are acidotic, it causes the Metabolic Acidosis. Compensation occurs because the pH and the CO2 go in the opposite direction, and the pH is not in the normal range to cause the partial.
2. The pH is acidotic, the CO2 is alkalotic, and the HCO3 is acidotic. Because the pH and the HCO3 are acidotic, it causes the Metabolic Acidosis. Compensation occurs because the pH and the CO2 go in the opposite direction, and the pH is not in the normal range to cause the partial.
3. Compensation occurs because the pH and the CO2 go in the opposite direction, and the pH is not in the normal range to cause the partial.
4. Because the pH and the HCO3 are acidotic, it causes the Metabolic Acidosis.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child has the following results for an ABG:

pH: 7.42

pCO2: 43.9

HCO3: 26.8

The nurse interprets these results to be:

  1. Compensated Respiratory Acidosis.
  2. Compensated Respiratory Alkalosis.
  3. Normal ABG.
  4. Compensated Metabolic Acidosis.

 

ANS: 3

Feedback
1. All results are within normal range and are not causing acidosis or compensation.
2. All results are within normal range and are not causing alkalosis or compensation.
3. All results are within normal ranges, thus this is a normal ABG finding.
4. All results are within normal range and are not causing compensation or acidosis.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 10-month-old boy is being given a sweat test because:
  2. The child has had several high fevers.
  3. The test is assessing for cystic fibrosis.
  4. The test is assessing for respiratory failure.
  5. The child does not demonstrate thermoregulation.

 

ANS: 2

Feedback
1. A child with a high fever does not require a sweat test. Sweating can be a normal occurrence during fevers.
2. The sweat test is a common test for cystic fibrosis diagnostics.
3. The sweat test will not give an indication as to respiratory failure.
4. The sweat test does not deal with the thermal regulation of a child.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Otitis media is a common infection children have when an upper respiratory illness is present because:
  2. The Eustachian tubes are short and immature.
  3. The immune system is extremely compromised and more susceptible to infections.
  4. Bottle feeding increases the risk in babies.
  5. All of the above are correct.

 

ANS: 1

Feedback
1. Eustachian tubes are short and do not provide adequate draining for mucous during an upper respiratory infection in children.
2. Immunity and susceptibility to infections cause the primary illness. Otitis media is a secondary illness.
3. A child that is positioned correctly during bottle feedings is not at an increased risk for otitis media.
4. Eustachian tubes are short and do not provide adequate draining for mucous during an upper respiratory infection in children, causing only one answer to be correct.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother has brought her 18-month-old boy into the pediatric clinic because of irritability, high fever, and has been tugging at his ear for the last 24 hours. The nurse would anticipate which of the following orders?
  2. Place the child NPO and attempt to get a head CT.
  3. Administering antibiotics for otitis media and acetaminophen for pain and fever control.
  4. No orders, as this is a common childhood ailment that requires no interventions.
  5. Admitting the child to the hospital to control the high fever.

 

ANS: 2

Feedback
1. A child with a high fever is normally irritable and this would not be an indication for a head CT as a first priority.
2. The tugging at the ear can be an indication of a child having otitis media. Acetaminophen can help control the ear pain and fever in order to help decrease irritability.
3. Due to the high fever and irritability, the child is demonstrating pain. An intervention is needed.
4. Not enough information is provided to indicate the fever level. Normally this can be controlled at home with acetaminophen.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother calls the triage nurse because her 8-year-old son is having trouble keeping his balance, but has otherwise appeared healthy for the past few days. The nurse should advise the mother to:
  2. Make a doctor’s appointment because the child could have issues with his inner ear.
  3. Take the child immediately to the ER because this is a neurological emergency.
  4. Ask the child if he has consumed any drugs or alcohol in the last few days.
  5. Call back in a few days with an update.

 

ANS: 1

Feedback
1. Unknown etiologies of unsteady balance are a sign of inner ear infections.
2. Since the mother feels the child is healthy and does not exhibit any other neurological symptoms, a doctor’s appointment is advisable.
3. A child would be exhibiting more symptoms than unsteady balance if he was taking a substance.
4. The concern should be addressed and an appointment made to find the cause of the unsteady balance.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Treatment for otitis externa (OE) is usually:
  2. No treatment because it resolves on its own.
  3. Antibiotic therapy.
  4. Corticosteroid therapy.
  5. Applying a warm pack to the area for comfort.

 

ANS: 3

Feedback
1. Treatment is recommended because long-term or frequent infections can cause hearing loss.
2. The concern is the fluid and inflammation. Antibiotics will not help remove the fluid and inflammation.
3. Corticosteroids will help reduce the inflammation and fluid in the ear.
4. The warm pack can be a comfort measure, but the fluid and inflammation need to be addressed.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Important discharge teaching for a 4-year-old boy who had a tympanostomy procedure done would include:
  2. The tubes usually fall out spontaneously within a year.
  3. Draining of purulent fluid after two days, then return for a follow-up.
  4. Placing waterproof ear plugs in the ears when swimming.
  5. All of the above should be included in the discharge teaching.

 

ANS: 4

Feedback
1. Because of the rapid growth of children, the tubes usually last approximately one year.
2. Purulent fluid is a sign of infection.
3. Preventing water from entering the tubes will help decrease the chance of infection.
4. Because of the rapid growth of children, the tubes usually last approximately one year. Purulent fluid is a sign of infection. Preventing water from entering the tubes will help decrease the chance for infection.

KEY: Content Area: HEENT | Integrated Processes: Teaching/Documentation | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An outbreak of influenza has occurred at the middle school. The school nurse is preparing to send home information about influenza. Her flyer should include all of the following except:
  2. The virus is contagious one to two days prior to the appearance of symptoms.
  3. Do not send your child to school if he/she has the chills or a erythematous rash.
  4. Hydration is important.
  5. If your child vomits, take them to the emergency room immediately.

 

ANS: 4

Feedback
1. The virus is most contagious one to two days prior to the appearance of symptoms.
2. Chills and a erythematous rash indicate fever and can cause the spread of the virus.
3. Hydration will help keep mucous membranes moist to remove secretions.
4. Vomiting may occur and is not a medical emergency.

KEY: Content Area: Illness | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Amantadine hydrochloride has been prescribed for a patient. The nurse knows this medication is used for:
  2. Sinusitis.
  3. Influenza.
  4. Upper respiratory tract infections.
  5. Asthma.

 

ANS: 2

Feedback
1. The medication is not prescribed for sinusitis.
2. The medication helps reduce the symptoms and spread of the influenza virus.
3. Upper respiratory tract infections do not benefit from the use of the medication.
4. Asthma exacerbations do not benefit from the use of this medication.

KEY: Content Area: Illness | Integrated Processes: Nursing Process| Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A child is scheduled to have a tonsillectomy in two hours. The nurse’s assessment should include:
  2. A question to see if the child snores or has difficulty breathing at times.
  3. Assessing for halitosis.
  4. The size of the tonsils.
  5. All of the above

 

ANS: 4

Feedback
1. Snoring and difficulty breathing are an indication of obstruction of the tonsils.
2. Halitosis is common in children with enlarged tonsils because of the bacterial content.
3. Tonsil size should be documented because removal of the entire tissue will need to occur during surgery.
4. Snoring and difficulty breathing are an indication of obstruction of the tonsils. Halitosis is common in children with enlarged tonsils because of the bacterial content. Tonsil size should be documented because removal of the entire tissue will need to occur during surgery.

KEY: Content Area: HEENT | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Following a tonsillectomy, a nurse should provide the patient with:
  2. Ice chips, no pillow, and no straw for drinking.
  3. Ice chips and orange juice.
  4. A sippy cup and pudding.
  5. A pillow, red Gatorade, and a straw.

 

ANS: 1

Feedback
1. The patient should lie flat to help clotting occur, ice chips will provide hydration, and no straw should be given because this can cause the clots to break and increase bleeding.
2. Orange juice should not be used because the pulp may lodge into the surgical site.
3. A sippy cup can cause clots to break because of the sucking motion and pudding is too thick to swallow at this point.
4. A patient should lie flat to help with clotting, Gatorade should not be used because you cannot assess for blood because of the color, and a straw will cause the clots to break and increase bleeding.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn is lying in his crib in the hospital nursery. The nurse picks up the newborn to prepare for a feeding and notes frothy oral secretions around the newborn’s mouth. The nurse should:
  2. Wipe the newborn’s mouth and give the feeding.
  3. Clean the newborn’s mouth and notify the doctor of the findings.
  4. Feed the newborn.
  5. Take the baby to the mother to feed.

 

ANS: 2

Feedback
1. The wiping the mouth for an assessment is needed, but the newborn should not be fed because the secretions are an indication of lack of secretion drainage.
2. These actions should occur because the child is at risk for tracheal esophageal atresia.
3. The newborn should not be fed because the secretions are an indication of lack of secretion drainage and increases the chance for aspiration.
4. The newborn should not be fed because the secretions are an indication of lack of secretion drainage and increase the chance for aspiration.

KEY: Content Area: Respiratory | Integrated Processes: Care | Client Need: Safe and Effective Care Environment | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn has had a repair of a trancheoesophageal fistula one hour ago. When the newborn is taken to the neonatal intensive care unit, the nurse should:
  2. Monitor the oxygen saturations of the newborn.
  3. Assess for respiratory distress.
  4. Provide oral suctioning as needed.
  5. All of the above should be done for the newborn.

 

ANS: 4

Feedback
1. Oxygen saturations will indicate the respiratory status of the newborn.
2. Assessment for respiratory distress is needed because the surgery requires some trauma to the trachea.
3. Suctioning is needed so the secretions do not cause blockage in the airway.
4. Oxygen saturations will indicate the respiratory status of the newborn. Assessment for respiratory distress is needed because the surgery requires some trauma to the trachea. Suctioning is needed so the secretions do not cause blockage in the airway.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother calls the pediatric triage nurse to report that her son has a barky cough, and it started about midnight. The nurse should instruct the mother to:
  2. Take the child to the emergency room right away.
  3. Sleep with the child in an upright position.
  4. Take the child into a room with a cool mist humidifier or go outside and see if the barky cough subsides.
  5. All of the above would be appropriate responses for the mother.

 

ANS: 3

Feedback
1. The mother should attempt to relieve the symptoms at home prior to coming to the emergency room.
2. The child will more than likely not sleep.
3. A cool mist humidifier or going outside can help reduce the inflammation of the trachea and larynx area.
4. Only using the cool mist humidifier or taking this child into the cool night is effective treatment.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When assessing a child with epiglotitus, the nurse should assess for all of the following except:
  2. Drooling.
  3. Dysphonia.
  4. Stridor.
  5. Crackles in the upper lungs.

 

ANS: 4

Feedback
1. Drooling can indicate swelling of the epiglottitis because the secretions are not able to go to the stomach.
2. Dysphonia can occur because of the swelling.
3. Stridor is common because of the swelling of the epiglottitis.
4. Crackles are heard in lower respiratory illnesses, not the upper respiratory illnesses in children.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 2 year old has been placed in contact isolation because of a diagnosis of Respiratory Syncytial Virus (RSV). The father questions why the staff is wearing masks and gowns every time someone comes into the room. The best response would be:
  2. “The equipment is needed to protect myself and others from your child’s illness.”
  3. “Since bronchiolitis is highly contagious for other children, it is important for the staff to wear the equipment to prevent spreading it to others.”
  4. “Every child that comes in with a respiratory illness is required to be in isolation.”
  5. “The equipment is needed to protect your child from acquiring an illness from the staff.”

 

ANS: 2

Feedback
1. The equipment is protecting the health-care worker from transmitting the virus to other patients.
2. Prevention of the spread of the disease is the primary reason for the equipment.
3. Not all respiratory illnesses require isolation.
4. The equipment is protecting the health-care worker from transmitting the virus to other patients.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a 3-month-old child with RSV. The nurse identifies the following: HR of 140; RR of 32; Oxygen saturation is 89% on room air; inspiratory and expiratory wheezing of the upper lungs; temperature of 38.1 degrees Celsius; large amounts of thin secretions. Identify the priority at this time.
  2. Administering acetaminophen to reduce the fever
  3. Providing oxygen for the low saturation
  4. Suctioning the nares and oropharnyx to remove the secretions
  5. Providing a quiet environment

 

ANS: 3

Feedback
1. The fever is low grade and not a priority at this time.
2. 89 percent oxygen saturation on room air needs to have a further assessment to see why the child is low in saturations.
3. Suctioning helps remove all the secretions and opens the airway with the possibility of increasing oxygen saturations.
4. A quiet environment will help the child rest, but is not a priority at this time.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A common cause of viral pneumonia in children is:
  2. The influenza virus.
  3. Streptococcus.
  4. Fungus.
  5. Beta-hemolytic streptococcus pneumoni.

 

ANS: 1

Feedback
1. Influenza is a common cause for viral pneumonia in children as a secondary infection.
2. Streptococcus is a bacterium, not a virus.
3. Fungus is not a virus.
4. Beta-hemolytic strep is bacterial, not viral.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The best way to prevent pertussis in children is with:
  2. Good hand hygiene.
  3. Keeping immunizations up-to-date.
  4. Isolation precautions.
  5. All of the above are correct.

 

ANS: 2

Feedback
1. Hand hygiene is important but the pertussis virus is usually airborne.
2. Immunizations help to build immunity to the disease.
3. Isolation precautions are needed after a child has the illness.
4. Immunizations to help build immunity to the disease is the priority.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A school nurse has been made aware that an eighth grader has latent tuberculosis (TB). Education for the teaching staff should include:
  2. A document with the signs and symptoms of illness for a person with TB.
  3. Do not allow the child into the classroom when he coughs. Send him to the nurse’s office to prevent the spread of the illness.
  4. Provide universal precautions with the child.
  5. The child does not need any interventions at this time because the TB is dormant.

 

ANS: 1

Feedback
1. A signs and symptoms document will help increase the awareness of the disease and can also help identify those who are infected early.
2. The spread of the disease cannot occur just because of coughing.
3. Universal precautions should be used with every student, not just the ill children.
4. Interventions will help prevent the illness from spreading.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A neonate has been diagnosed with respiratory distress syndrome. The nurse notes the neonate is retracting and is hypoxic. The best intervention at this time would be:
  2. Providing oxygen support via a mask.
  3. Providing oxygen support via nasal cannula.
  4. Attempt to reposition the neonate.
  5. Check the temperature of the neonate so that the child does not experience cold stress.

 

ANS: 1

Feedback
1. Oxygen delivered by mask is the highest percentage of oxygen to be delivered other than intubation.
2. The neonate does not receive as high of a rate of oxygen saturation with a nasal cannula.
3. Repositioning may open the airway more, but the retracting occurs because of deterioration, thus requiring oxygen support.
4. Cold stress can cause respiratory issues, but is short term once the neonate is warm.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. When assessing a newborn with a known diaphragmatic hernia, the nurse would anticipate hearing bowel sounds:
  2. In the upper abdomen.
  3. In the lower abdomen.
  4. To not exist.
  5. In the chest.

 

ANS: 4

Feedback
1. Normal bowel sounds can be heard in the upper abdomen.
2. Normal bowel sounds can be heard in the lower abdomen.
3. Bowel sounds do exist, just in a different area of the body.
4. Because of the lack of diaphragm, the gastrointestinal tract is shifted into the chest cavity.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is repositioning an infant with a known diaphragmatic hernia. The nurse should place the infant in which position?
  2. With the head of bed elevated 20 degrees
  3. Supine
  4. Prone
  5. In a semi-fowlers position

 

ANS: 4

Feedback
1. This position does not take enough pressure off of the respiratory muscles.
2. Supine can cause the collapsing of the chest cavity and increase difficulty breathing.
3. Prone can cause too much pressure on the respiratory muscles and not allow for expansion.
4. Semi-fowlers will allow for pressure to be taken off of the diaphragm and decrease difficulty breathing.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Clubbing of the nailbeds in the fingers would be a clinical finding on which patient?
  2. A child with cystic fibrosis
  3. A child with croup
  4. A child with respiratory distress syndrome
  5. A child with RSV

 

ANS: 1

Feedback
1. Long-term hypoxia causes clubbing of the nailbeds because of the lack of oxygen.
2. Croup is a short-term respiratory issue, which does not causing clubbing.
3. Respiratory distress syndrome is short lived and does not cause clubbing.
4. RSV is short lived and does not cause clubbing.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Children with cystic fibrosis should be frequently checked for:
  2. Hypernatremia.
  3. Hypocalcemia.
  4. Hyponatremia.
  5. Hypercalcemia.

 

ANS: 3

Feedback
1. High sodium is not an issue in children with cystic fibrosis.
2. Low calcium levels are not an issue for children with cystic fibrosis.
3. The lack of sodium is noted in children with this diagnosis.
4. High calcium levels are not common in children with cystic fibrosis.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An 8-year-old boy with a long history with cystic fibrosis has been admitted for malnutrition. The doctor has ordered labs for the child. The nurse clarifies which doctor’s order before proceeding?
  2. Obtain a stool sample for Clostridium difficile
  3. Metabolic panel for hydration status
  4. Serum albumin level to measure the nutritional status
  5. Provide chest physiotherapy before bedtime

 

ANS: 1

Feedback
1. A stool sample should be used for the absence of trypsin.
2. Malnutrition may be caused by metabolic issues.
3. Serum albumin levels will help indicate nutritional status and are appropriate for this patient.
4. Chest physiotherapy is needed at bedtime to rid as many secretions as possible prior to lower activity levels.

KEY: Content Area: Respiratory | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Teaching a child with a chronic respiratory illness to forcefully exhale can be done by:
  2. Pretending to blow candles out.
  3. Blowing bubbles.
  4. Pretending to blow out a flashlight.
  5. All of the above are techniques for teaching a child to forcefully exhale.

 

ANS: 4

Feedback
1. This requires a large volume for inhalation and expiration, thus being an effective treatment.
2. This requires pursed-lip breathing and helps force air, thus being an effective treatment.
3. This requires a large volume for inhalation and expiration, thus being effective treatment.
4. Pretending to blow out candles or a flashlight require a large volume for inhalation and expiration, thus being effective treatment. Blowing bubbles requires pursed-lip breathing and helps force air, thus being an effective treatment.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A diet for a child with cystic fibrosis should include:
  2. Foods with high protein and high fat content.
  3. Foods with low fat and high protein content.
  4. A daily dose of fat-soluble vitamin supplements.
  5. A daily dose of water-soluble vitamin supplements.

 

ANS: 3

Feedback
1. A diet with a high fat content can cause digestion issues because of the lack of enzymes.
2. A diet with low protein is needed for the child to aid in health.
3. The fat-soluble vitamins are needed because the child is not able to digest fat easily.
4. A child with cystic fibrosis should be able to receive the needed water-soluble vitamins in a regular diet.

KEY: Content Area: Nutrition | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A nurse is attempting to educate a 10-year-old girl in the use of a peak flow meter. Identify the best way to explain the test to the child.
  2. “The purpose of the test is to see how hard you breathe.”
  3. “The purpose of the test is for you to monitor what is normal and abnormal for you. Then your parents can help with your medication on days when you are not measuring in your normal ranges.”

3: “We are measuring how well you can blow birthday candles out.”

  1. “The meter will help monitor when you are healthy and when you are becoming ill.”

 

ANS: 4

Feedback
1. The description is not accurate, and a 10 year old is able to comprehend the reason for use of a peak flow meter.
2. The description of normal and abnormal can cause concern for the child. It is important to explain that the peak flow meter is a measurement of health.
3. This description can be used for a younger child. A 10 year old is able to comprehend the use of the peak flow meter.
4. The peak flow meter is a monitor used to indicate when the child is breathing easily and when illness may be starting.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn is experiencing apneic episodes. The nurse should do which of the following when an episode occurs?
  2. Give the newborn CPR
  3. Stimulate the newborn by rubbing its back
  4. Reposition the newborn
  5. Hold the newborn

 

ANS: 2

Feedback
1. An assessment to see if the newborn has a heart rate is needed.
2. Stimulating the newborn may help his/her breathing.
3. Repositioning the newborn is important and should occur after breathing stimulation is provided.
4. Holding the newborn will not stimulate him/her to breathe.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A former 24-week, premature infant is now adjusted in age to be one year of age. The baby has a known history of bronchopulmonary dysplasia. The parents of the child are asking if their baby will catch up in height and weight to her peers by the time she is 2 years old. The best reply from the nurse would be:
  2. “Normally, premature infants will be the same height and weight as their peers by their second birthday.”
  3. “The bronchopulmonary dysplasia requires your child’s lungs to work harder to breath. This causes the body to have a higher metabolism, so she may remain on the small side for several years.”
  4. “You baby is now healthy and will continue to grow at her own rate.”
  5. “Your baby will remain small for most of her life due to the bronchopulmonary dysplasia.”

 

ANS: 2

Feedback
1. Children with bronchopulmonary dysplasia require high nutritional demands to the body. The growth of children with this diagnosis tends to be slower than their peers.
2. Children with this diagnosis tend to be smaller than their peers for a longer period of time.
3. This is a true statement, but does not address why the child is not growing at the same rate.
4. The child’s body can grow and may be the same as peers later in life.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The nurse is assessing a child that was in a motor vehicle accident, which occurred two hours ago. The child’s chest is not rising on the right and lacks lung sounds. The X-ray confirmed a hemothorax. The nurse should anticipate the order for:
  2. A chest tube and pnuemovac.
  3. IV fluids.
  4. Placing a nasogastric tube.
  5. None of the above would be appropriate for the situation.

 

ANS: 1

Feedback
1. The pnuemovac will aid in the creation of a sterile container to help decompress the hemothorax.
2. IV fluids may be ordered eventually, but they are not a priority at this time. Airway security is the priority.
3. A nasogastric tube will not influence the hemothorax.
4. The nurse should anticipate the use of the pneumovac to help decompress the hemothorax.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The purpose of administering surfactant to a preterm neonate is:
  2. Because the preterm neonates lungs do not produce it.
  3. To prevent the alveoli from collapsing.
  4. To help the diaphragm function.
  5. Because a preterm neonate needs more surfactant than an older child.

 

ANS: 2

Feedback
1. Preterm neonates do have some surfactant in the lungs, but not enough to keep the alveoli open for a long period of time.
2. Surfactant is the lubricant in the lungs that allows all for alveoli to remain moist and prevents them from collapsing.
3. The diaphragm is outside of the lung tissue and does not receive surfactant.
4. A preterm neonate’s needs do not differ from those of an older child.

KEY: Content Area: Respiratory | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The mother of a child with cystic fibrosis calls the triage nurse and asks which type of antihistamine would be the most beneficial for her son’s head cold. The nurse should:
  2. Recommend Benadryl for her son.
  3. Discourage the use of antihistamines because the drug can dry out the mucous and make it harder to expel.
  4. Encourage the mother to give the child a dose of the antihistamine every four hours.
  5. Recommend any over-the-counter antihistamine that states it is a pediatric formula.

 

ANS: 2

Feedback
1. Benadryl will dry out the mucous membranes and cause further problems for the child.
2. Discouragement of antihistamine usage is important because the medication can dry out the mucous membranes too much for a child with cystic fibrosis.
3. Antihistamine medication can dry out the mucous membranes too much for a child with cystic fibrosis, creating further problems.
4. Antihistamine medication can dry out the mucous membranes too much for a child with cystic fibrosis and create further problems.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The mother of an 18 month old states that she is concerned due to the fact that her child has been diagnosed with otitis media three times in the last year. Which answer would be appropriate to alleviate the mother’s concerns?
  2. A child’s airway is short and narrow. As the child grows, the airway will grow, and the number of alveoli will increase.
  3. A child’s tonsils are larger than an adult’s and block emptying of the Eustachian tubes. As the child grows, the tubes get longer even though tonsils don’t change.
  4. A child’s Eustachian tubes are shorter and more horizontal, allowing nasopharyngeal secretions to enter. As the child grows, the incidence of OM will decrease.
  5. A child’s larynx is more flexible than an adult’s and easily stimulated to spasm. As he grows, he will be less sensitive to laryngospasms and pooling of secretions.

 

ANS: 3

1. Although choice 1 is correct, it does not address the ears and recurrent infection.
2. A child’s tonsils are not larger than an adult’s. They do not block the emptying of the Eustachian tubes.
3. A child’s Eustachian tubes are shorter and more horizontal, allowing nasopharyngeal secretions to enter. As the child grows, the incidence of OM will decrease.
4. A child’s larynx is not more flexible than an adult’s.

KEY: Content Area: Basic Care and Comfort | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The mother of a 3 year old complains to the nurse after the physician leaves the room, saying, “My baby is sick with a fever, bad cough, runny nose, and flushed cheeks. He didn’t give me any medicine to make him better!” What is the nurse’s best response?

 

  1. “It is okay to give your child over-the-counter medicine. Just make sure you get a cold and fever medication.”
  2. “The doctor stated that he believes this to be a virus, so antibiotics will not relieve the symptoms.”
  3. “The best way to treat your child is to give him plenty of fluids, bedrest, and coloring books.”
  4. “The doctor believes this to be a viral illness, so you can use over-the-counter cold medications as long as they say ‘pediatric’ on the label.”

 

ANS: 2

1. You should not use cold medicine in children under the age of 5.
2.  “The doctor stated that he believes this to be a virus, so antibiotics will not relieve the symptoms.”

 

3. Fluids, bedrest, and limiting contacts would help the management of current symptoms. This does not address the mother’s concern of not receiving medication.
4. You should not use cold medicine in children under the age of 5.

KEY: Content Area: Comfort and Care | Integrated Processes: Teaching Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 6 year old had a tonsillectomy today. When the nurse goes into the room to give him his antibiotics, she finds him irritable, coughing, nauseated, and swallowing repeatedly. What is the next action the nurse should take?
  2. Assess for signs of frank red blood in the mouth and nose and get a complete set of vital signs.
  3. Ask the child for a pain score and if he would like a popsicle with his pain medicine.
  4. Suction mouth vigorously to avoid aspiration of blood, and then hang antibiotic.
  5. Take a complete set of vital signs and divert the child’s attention to the cartoon on TV.

 

ANS: 1

Feedback
1. This intervention assesses for bleeding.
2. An assessment for blood needs to occur because the child continues to swallow.
3. Suctioning can cause clots to loosen and increases bleeding. It should be avoided.
4. Vital signs are needed and a focused assessment needs to be completed in order to identify complications.

KEY: Content Area: Care and Comfort | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A father brings his 6-month-old infant into the clinic with a four day history of nighttime, seal-like cough. The infant is afebrile, tachycardic, and tachypneic with a pulse oximetry reading of 98 percent. What interventions would you expect the physician to order for this child?
  2. Cool mist tent with supplemental oxygen, racemic epinephrine, and corticosteroids
  3. Beta adrenergics aerosolized, cool mist tent, and periodic testing of blood glucose levels
  4. Close monitoring of respiratory status, cool mist tent, beta adrenergics, and corticosteroids
  5. Close monitoring of respiratory status, supplemental oxygen with simple mask, and racemic epinephrine

 

ANS: 3

Feedback
1. The infant’s pulse oximetry is 98 percent and does not need supplemental oxygen.
2. Beta adrenergic meds do not increase blood glucose levels.
3. These interventions are appropriate for croup-like symptoms.
4. The infant’s pulse oximetry is 98 percent and does not need supplemental oxygen.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An 8 month old was admitted to the hospital last night with cold symptoms and respiratory distress. She is on a simple mask with a flow rate of 10 L and on a cardiorespiratory monitor. The nurse goes into the infant’s room to find her tachypneic, retracting, and slightly cyanotic with a pulse oximetry of 90%. What would be the oxygen delivery system that may help the infant?
  2. A venturi mask with an oxygen flow of 1 liter per minute.
  3. A nasal cannula with an oxygen flow of 4 liters per minute.
  4. An oxygen tent with an oxygen flow rate of 10 liters per minute.
  5. A partial rebreather mask with an oxygen flow rate of 8 liters per minute.

 

ANS: 4

Feedback
1. The pressure is not adequate to oxygenate the infant.
2. A nasal cannula does not deliver enough pure oxygen to raise the oxygen saturation of the infant.
3. The oxygen tent will not allow for enough pressure for the infant to raise the oxygen saturation.
4. A partial rebreather mask with an oxygen flow rate of 8 liters per minute will raise the oxygen saturation of the infant.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A mother brought her 8 year old into the emergency room because although she was fine when she woke up this morning, she now has a fever of 39.8 C, cannot speak, is drooling, and is tachypneic and stridorous. Her pulse oximetry reading is 90 percent on a rebreather mask. What would be the next appropriate nursing action?
  2. Suction her mouth, then conduct throat and blood cultures as well as a test for gram positive bacteria.
  3. Prepare the child and mother for an MRI scan to evaluate for a “thumb sign.”
  4. Monitor respiratory status closely, prepare for intubation, and keep the child calm to avoid crying.
  5. Suction her mouth, monitor respiratory status closely, and give a Palivizumab injection.

 

ANS: 3

Feedback
1. Suctioning can cause more traumas to the area.
2. The “thumb sign” will not occur in this condition.
3. The nurse would monitor and be prepared for possible rapid decline in respiratory status and try to keep the child from crying.
4. Suctioning the mouth can cause more damage, and the injection should not be given at this time.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. What is the most accurate statement regarding Palivizumab?
  2. It is a humanized monoclonal antibody given as an IM injection before the start of HPV season.
  3. It is recommended for premature infants with 29-35 week’s gestation, children with congenital heart defects, and the elderly.
  4. It is costly and is given usually between October to May in a series of five injections.
  5. Before administering, you need to evaluate results of complete blood count and electrolyte panel from the laboratory.

 

ANS: 3

Feedback
1.  Given prior to RSV season
2. Not given to the elderly
3. It is given prophylactically before the start of RSV season. The nurse needs to evaluate platelets and coagulants before administering.
4. The nurse needs to evaluate platelets and coagulants before administering.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 15 month old admitted with croup is sleeping in a cool mist tent. The nurse checks on him and notices that he is retracting and tachypneic. What is the first thing she should do?
  2. Increase the oxygen flow to the tent
  3. Check the child’s pulse oximetry
  4. Check the child’s temperature
  5. Notify the physician

 

ANS: 2

Feedback
1. This is not the first intervention. A pulse oximetry should be assessed to identify the need for oxygen.
2. The first intervention should be to check the child’s pulse oximetry.
3. Fever can cause tachypnea. This is not the first action needed.
4. Notifying the physician is not the first action needed.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An infant born an hour ago exhibits coughing and drooling, cyanosis, abdominal distention, and moderate retractions and grunting. Based on these symptoms, what would be the most likely diagnosis?
  2. Tracheoesophageal fistula
  3. Laryngomalacia
  4. Respiratory distress syndrome
  5. Bronchopulmonary dysplasia

 

ANS: 1

Feedback
1. Tracheoesophageal fistula is the most likely diagnosis.
2. Laryngomalacia would cause more grunting.
3. The child may initially present similar respiratory distress, but the drooling indicates that more is involved.
4.  Bronchopulmonary dysplasia occurs after long-term ventilator support, not soon after birth.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 12 year old comes in with her mother and has the following symptoms: a 40.0 C fever, chills, coughing, and chest pains. Her mother states that she just finished Amoxicillin for strep throat and her chest x-ray shows consolidation. Based on these findings, what would be possible nursing interventions to manage this patient?
  2. Monitor oxygenation status and results of sputum culture, CBC, PTT, and sweat chloride test from the laboratory
  3. Monitor respiratory, oxygenation, and hydration status and give antibiotics as ordered
  4. Monitor respiratory and oxygenation status and give pneumococcal vaccine injection as ordered
  5. Monitor oxygenation and hydration status and inform mother that antibiotics would be ineffective for her daughter

 

ANS: 2

Feedback
1. A PTT and sweat chloride test are not needed at this time because this is the initial incidence of respiratory issues.
2. Although RSV causes 80%85% of all pneumonia in children, the nurse suspects bacterial pneumonia due to the recent strep infection. This is why antibiotics are expected to be ordered.
3. A pneumococcal vaccine should be given prior to the illness.
4. Although RSV causes 80%85% of all pneumonia in children, the nurse suspects bacterial pneumonia due to the recent strep infection. Antibiotics can be effective in this situation.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. It is May, and a mother brings in her 3-year-old son, who has had a harsh whooping cough, runny nose, and watery eyes for the past five days. What would be the most appropriate question to ask the mother?
  2. Are the child’s immunizations up-to-date, including his Tdap vaccine?
  3. Did the child receive his Hib vaccine?
  4. Have you taken the child outside in the rain? If so, what happened?
  5. When was the last time your child was ill?

 

ANS: 1

Feedback
1. Up-to-date immunizations will include the Tdap vaccine.  If the child has had the vaccine the occurrence/severity of the illness is less.
2. Hib does not include the Whooping Cough vaccine.  The question would not be appropriate at this time.
3. Weather does not influence the vaccines.
4. Past illnesses is not the focus of the current assessment and is not appropriate at this time.

KEY: Content Area: Wellness | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. You suspect a 14 year old with persistent cough, anorexia, low-grade fever, and night sweats has tuberculosis. What is the most accurate statement about the treatment of this patient?
  2. A nurse needs to collect serial sputum cultures in the a.m. and do serial AFB tests.
  3. Latent TB would be treated with antituberculin medication combinations in higher doses for nine months.
  4. Anti-tubercular medications given in higher doses in combination for six months are only effective after BCG vaccine is given.
  5. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.

 

ANS: 4

Feedback
1. The time of day does not influence when the sample should be taken.
2. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.
3. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.
4. Active TB is treated with combinations of rifampicin, isoniazid, ethambutol, and streptomycin in higher doses for six months.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Which statement regarding the pathophysiology of TB is accurate?
  2. The settling of the bacillus in the alveoli triggers the clotting response.
  3. Macrophages form hard tubercules around bacilli that always remain dormant in the lungs.
  4. TB can affect the lungs, spinal cord, bone formation and the brain.
  5. Tubercles in the lungs can remain dormant or progress to active tuberculosis, but are not as prevalent in children.

 

ANS: 4

Feedback
1. The clotting response is not triggered by the bacillus.
2. The tubercules are rare in children.
3. TB affects the lungs only.
4. Tubercles in the lungs can remain dormant or progress to active tuberculosis, but are not as prevalent in children.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The nurse is doing discharge teaching with the mother of a 10 year old, who has been newly diagnosed with TB. Which statement is not accurate regarding the spread of TB?
  2. The patient should take anti-tubercular medicine for two weeks before being exposed to any non-infected people.
  3. Everyone should wash their hands or use sanitizer after exposure to respiratory secretions.
  4. It is transmitted through inhaled droplets from a close contact that is infected.
  5. About 460,000 new cases of multi-drug sensitive TB are reported every year because of incomplete treatment regimes.

 

ANS: 4

Feedback
1. The medication will be needed for this length of time before being exposed to others.
2. Washing of hands should occur with every patient.
3. Close contact with those who have the disease increases the risk.
4.  This statement is not accurate.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn, premature twin exhibits respiratory distress with retractions, nasal flaring, cyanosis, grunting, and fine, scattered rales. What nursing interventions would you expect the physician to order?
  2. Place an NG tube for feeds, monitor respiratory status on ventilator, record I& O’s, start an IV, and send electrolyte panel to the laboratory and monitor temperatures
  3. Cardio- respiratory monitoring, frequent suctioning on ventilator, and monitoring blood glucose level hourly
  4. Placing infant in semi-fowler’s position on affected side with head of the bed elevated, oxygen via nasal cannula, keeping NPO, and preparing parents for surgery
  5. Giving surfactant intravenously within the first 12 hours of life and repeating every 12 hours for three days.

 

ANS: 1

Feedback
1. Place an NG tube for feeds, monitor respiratory status on ventilator, record I& O’s, start an IV, and send electrolyte panel to the lab and monitor temperatures
2. A ventilator is not needed at this time. Blood glucose should be monitored because it can cause an increase in respiratory distress.
3. Surgery is not indicated at this time.
4. The statement does not indicate the level of prematurity for the infant. Surfactant is not needed at this particular time.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A newborn has a scaphoid-shaped abdomen, irregular chest wall movements, and decreased breath sounds on the left side of chest. What other symptoms would you expect to find?
  2. Central cyanosis and pink nailbeds with brisk capillary refill
  3. Protruding abdomen and fullness with palpation
  4. Increased breath sounds over trachea, tachypnea, and stidor
  5. Tachypnea, nasal flaring, and retractions

 

ANS: 4

Feedback
1. Nailbeds will be cyanotic and exhibit slow capillary refill.
2. The abdomen will be full and stiff because of excessive air.
3. Grunting may be present, and there will be decreased breath sounds.
4. Tachypnea, nasal flaring, and retractions are the correct symptoms.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Cystic fibrosis is best categorized as:

 

  1. An autosomal recessive disease with deletion of Chromosome 17 that affects the lungs and finances of the parents.
  2. An autosomal recessive disorder of the exocrine glands marked by increased mucus and sodium chloride production and decreased pancreatic enzyme production.
  3. An autosomal recessive disorder that affects the respiratory, cardiac, and digestive systems.
  4. An autosomal recessive disorder that is marked by the increased mucus destruction and decreased pancreatic enzyme production.

 

ANS: 2

Feedback
1. Cystic fibrosis is an autosomal recessive disorder of exocrine glands and is not seen on chromosome 17.
2. Cystic fibrosis is an autosomal recessive disorder of exocrine glands marked by increased mucus and sodium chloride production and decreased pancreatic enzyme production.
3. Cystic fibrosis is an autosomal recessive disorder that impacts the respiratory and GI tract, not the heart.
4. Cystic fibrosis is an autosomal recessive disorder of the exocrine glands marked by increased mucus and sodium chloride production and decreased pancreatic enzyme production.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. Which statement is most accurate regarding chest physiotherapy (CP)?
  2. CP includes postural drainage, chest percussion, vibration, and daily chest x-rays.
  3. CP is used to mechanically loosen secretions to prevent or manage atelectasis and gastritis.
  4. CP should only be performed in the absence of respiratory distress.
  5. CP is contraindicated when chest rib fractures, lung contusions, or hemothorax are present.

 

ANS: 4

Feedback
1. CP does not require daily X-rays.
2. CP is not used for gastritis.
3. CP should only be done with patients with an increase in respiratory secretions.
4.  Chest physiotherapy is contraindicated when rib fractures, lung contusions, or hemothorax are present because further damage can occur.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. A 6 year old who exhibits a moist, productive cough has a history of bronchitis several times every year and “eating everything in sight.” She appears thin for her age and has a sweat chloride test that is 67 mEQ/L. Her mother states, “I just want to get this eating disorder treated so my baby can have a normal life.” What is the nurse’s best response?
  2. “We will consult the dietician for a behavior management and eating plan, focusing on appropriate portion size.”
  3. “We will need to do another sweat chloride test next week. Have your child take supplemental water-soluble vitamins, such as A, D, K and iron.”
  4. “You should incorporate tofu and mayonnaise in your meal preparation to promote feeling full for a longer period of time.”
  5. “Cystic fibrosis can cause an increase in appetite because of the lack of nutrients and calories absorbed. This affects children across the life span.”

 

ANS: 4

Feedback
1. Food choices that contain the needed vitamins and minerals should be discussed.
2. The child already has the diagnosis and another test will not indicate which vitamins to give.
3. This diet will not easily be digested by a person with CF. The menu should be reconsidered.
4. Increased appetite is a physiologic response to decreased fat-soluble nutrients and calories absorbed in the CF digestive track.  This requires fat-soluble (A,D, E, K) vitamins and pancreatic enzyme supplements.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The nurse is doing discharge teaching with the parents of a child with new diagnosis of CF. What is the most important concept for parents of CF patients to remember?
  2. Hospitalizations can be avoided with consistent chest physiotherapy.
  3. There are multiple support groups in the community available to help them cope when the symptoms increase as the child grows older.
  4. It affects multiple body systems over a lifetime, which requires vigilant respiratory care and individualized dietary modifications.
  5. All symptoms of cystic fibrosis can be managed by diet modifications and increasing the fluids and salt intake of the child.

 

ANS: 3

Feedback
1. Multiple adaptations to the lifestyle will be needed to maintain a healthy body and avoid hospitalizations.
2. Support groups and summer camps should be implemented right away to learn how to adapt to the illness emotionally.
3. It affects multiple body systems over a lifetime, which requires vigilant respiratory care and individualized dietary modifications.
4. Some individuals will be more ill than others and need different modifications to their diet.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. What is the major contributing factor for the development of BPD?
  2. Immature lungs have a decreased number of alveoli for gas exchange
  3. Premature birth with decreased number of functional alveoli, leading to lung injury
  4. Chronic respiratory infections, leading to pulmonary hypertension and lung scarring
  5. Ventilator assistance with high oxygen flow rate at birth, causing inflammation and scarring in lungs

 

ANS: 4

Feedback
1. BPD occurs because of the increased resistance and amount of damaged alveoli, decreasing the amount of oxygen exchange.
2.  Scarring occurs on the alveoli that are present. The preemie baby has the same amount of alveoli, but less surface area to ventilate.
3. Neonates do not commonly have respiratory infections to cause an increased risk for BPD.
4. Ventilator assistance with high oxygen flow rate at birth, causing inflammation and scarring in lungs

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. If a nurse suspects that a 2-month-old infant’s death was related to SIDS, what statement made by the mother reflects an accurate understanding of SIDS?
  2. “I knew that I should not have given our baby the antibiotics for the ear infection.”
  3. “Being a twin with low birth weight, he didn’t have a chance.”
  4. “I should not have fed him that eight-ounce bottle before laying him down.”
  5. “I am having a hard time not knowing what happened. I had just checked on him 20 minutes earlier in the crib, and he was sleeping on his back.”

 

ANS: 4

Feedback
1. SIDS is a diagnosis of exclusion. Antibiotics are not known to cause SIDS.
2. A lower birth weight child is at more risk, but is not the only reason SIDS can occur.
3. The amount of feeding does not influence the occurrence of SIDS.
4. SIDS is a diagnosis of exclusion. It is difficult to know what exactly causes the death in SIDS cases.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. An infant is tachypneic, retracting, and tachycardic with a temp of 39.0 C and a pulse oximetry of 92 percent. You place the infant on 1L nasal cannula oxygen and raise the head of the bed. What intervention would the nurse expect the physician to order next?
  2. MRI
  3. CT
  4. Bronchoscopy
  5. Chest x-ray

 

ANS: 4

Feedback
1. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.
2. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.
3. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.
4. A chest x-ray is the least invasive and can visualize the lung fields. The other answers require sedation, making the infant NPO prior to studies.

KEY: Content Area: Respiratory Therapy | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The parents of a 3 year old from India state that the child has been losing weight and coughing for a year. Additionally, the child’s grandmother was diagnosed with TB. Which of the following is the most accurate statement regarding this situation?
  2. Tubercules are more prevalent in children than adults, and all family members should be tested for TB.
  3. Prevalence is high in developing countries, and only 20 percent of complete treatment because the length, intensity, and cost of treatment.
  4. A blood culture is the definitive diagnosis for TB after a negative skin test.
  5. Diagnosing TB in children is difficult because it varies with the changes in the seasons, and the symptoms can be vague.

 

ANS: 2

Feedback
1. TB is more prevalent in adults than children.
2. Prevalence is high in developing countries, and only 20 percent of complete treatment because the length, intensity, and cost of treatment.
3. The Mantoux test gives an indication as to whether TB is present in the person’s body.
4. TB presents the same no matter the season in both children and adults.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice

 

 

 

  1. The most accurate physiologic reason for respiratory distress in respiratory distress syndrome (RDS) is:
  2. Altered surface tension causes fluid and protein leak, preventing atelectasis and ground glass appearance on CXR.
  3. Infants with RDS are premature and incidence of RDS increases with increased gestational age.
  4. Infants with RDS have a decreased number of alveoli, increased surface tension, and decreased AP diameter, limiting lung development.
  5. Infants with RDS have altered surface tension, which produces hyaline membrane, atelectasis, and hypoventilation.

 

ANS: 4

Feedback
1. The hypoventilation occurring in RDS causes an increased risk.
2. RDS can occur in any gestational age neonate.
3. The neonates have damage to the alveoli, not a decreased number.
4. Infants with RDS have altered surface tension, which produces, hyaline membrane, atelectasis and hypoventilation.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiology Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice

 

 

 

Multiple Response

 

 

 

  1. Signs that a child is exhibiting respiratory distress include: (Select all that apply.)
  2. Nasal flaring.
  3. Synchronized rise and fall of the abdomen and the chest.
  4. A capillary refill of less than three seconds.
  5. Grunting.
  6. Intercostal retractions.

 

ANS: 1, 4, 5

Feedback
1. Nasal flaring indicates that the child is struggling with breathing.
2. Synchronized rise and fall is a normal breathing pattern of a child.
3. A capillary refill of less than 3 seconds is normal for a child.
4. Grunting indicates that the child has to exhale harder than normal, thus indicating respiratory distress.
5. Intercostal retractions indicate that the child needs to use accessory muscles, creating respiratory distress.

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response

 

 

 

  1. The father of a 13-year-old boy with sinusitis calls the triage nurse at the pediatric clinic to ask what he can do to rest. The nurse should advise the father to: (Select all that apply.)
  2. Place a cold compress on the infected sinus areas.
  3. Have the child blow his nose with one nostril closed off at a time.
  4. Use a warm mist humidifier in his bedroom.
  5. Use saline drops to help clear the nasal passage.
  6. Use a bulb syringe to remove secretions.

ANS: 2, 4, 5

Feedback
1. Cold compresses will not encourage drainage.
2. Attempting to blow a nose with one nostril closed at a time helps provide pressure to remove the secretions.
3. A cool mist humidifier should be used to help reduce the chance of steam burns.
4. Saline drops can keep the airways moist and help remove secretions.
5. The child is too old for bulb syringe suction. Blowing the nose is just as effective.

KEY: Content Area: HEENT | Integrated Processes: Teaching/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter11 | Type: Multiple Response

 

 

 

  1. A nurse is giving discharge instructions to parents taking a newborn home with apneic episodes. The newborn has an apnea monitor for home. The instructions should include: (Select all that apply.)
  2. How to clean the monitor pieces.
  3. Allowing the monitor to be off when the parents are sitting with the newborn in an awake state.
  4. Never take the monitor off.
  5. Take the monitor off when bathing the baby.
  6. Reset the alarm limits if the monitor is ringing frequently.

 

ANS: 1, 2, 4

Feedback
1. Keeping the pieces clean will aid in decreasing the chances for infection and help maintain a working monitor.
2. The newborn can be off the monitor while awake, and being supervised helps decrease skin breakdown.
3. The monitor should be taken off for periods while the newborn is awake and supervised.
4. Since the monitor is electric, it should not become wet at any time.
5. The alarm limits are prescribed by a provider and should not be reset.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response

 

 

 

  1. Parents are attending a pre-baby class and receiving information on SIDS. Identify important information the nurse should provide during the course. Select all that apply.
  2. A firm mattress
  3. A bendy bumper around the entire bed
  4. A pillow
  5. Tight-fitting sheets
  6. A well-ventilated room

 

ANS: 1, 4, 5

Feedback
1. A firm mattress keeps the baby from sinking into the bedding, thus preventing suffocation.
2. Bendy bumpers can create pockets for the infant’s face to become stuck, thus creating a suffocation risk.
3. A pillow is too bulky and can cause an infant to become stuck, thus creating a suffocation risk.
4. Tight-fitting sheets decrease the chance for suffocation because there is little room for the infant’s head to get stuck.
A well-ventilated room creates air movement and a good exchange of oxygen and carbon dioxide.

KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response

 

 

 

Matching

 

 

 

  1. A nurse is discussing the process in which tuberculosis can infect a child. Place the following in the correct order.

__ Sputum specimen is obtained

__ Tubercles are dormant

__ Bacillus triggers the immune response

__ Bacilli spread to the lymphatic system

__ Macrophages form tubercles around bacilli

ANS: 5, 4, 1, 3, 2

KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Matching