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A nurse providing teaching to a client who is diagnosed with migrane headaches. The client is prescribed ergotamine (Ergostat) sublingual (SL). Which of the following should the nurse include in her instructions: 1) Take 1SL tablet three times a day before meals 2) Take 1SL tablet at onset of migrane A nurse is reviewing a client&039;s daily laboratory findings before administering 0.125 mg of digoxin (Lanoxin). The client&039;s serum digoxin level is 0.7 ng/mL. Which of the following actions should the nurse take: 1) Give the medication 2) Request a dose increase A nurse is planning to provide medication education for a client who will begin a course of therapy with metronidazole (Flagyl). Which of the following should the nurse instruct the client to avoid during the course of therapy: 3) Coffee
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Incision for GYN Pelvic Surgery and Prostatic Surgery - ANSWERS,Pfannenstiel incision Normal Hemoglobin levels for men - ANSWERS,13.5-17.5 Normal Hemoglobin for women - ANSWERS,12-16 Na+ normal level - ANSWERS,135-145 Normal Potassium Level - ANSWERS,3.5-5.0 Normal Ph level - ANSWERS,7.35-7.45 PaCO2 normal level - ANSWERS,35-45 PaO2 normal level - ANSWERS,80-100 HCO3 normal level - ANSWERS,22-28 Ammonia normal level - ANSWERS,9.5-49mcg/dl ALT liver function normal level - ANSWERS,0-35 Albumin normal level - ANSWERS,4-6 Hct normal level for male - ANSWERS,39-49 Hct normal level for female - ANSWERS,35-45 What piece of equipment do you need for a vasvagotomy? - ANSWERS,microscope During a procedure under local anesthesia, the patient complains of circumoral numbness, blurred vision and dizziness. What should be the immediate action of the preoperative nurse monitoring this patient? - ANSWERS,Ensure an airway The circulating nurse reports that the needle count is incorrect. The surgeon continues to close the wound stating "I know it is not in the wound and I am not going to stop to look for it". The best plan of action is to : - ANSWERS,inform the surgeon of the hospital policy and document subsequent actions A new employee unknowingly dispensed an unsterile solution to the sterile field. The following day the supervisor learns of the incident. The supervisors first action would be to: - ANSWERS,Notify surgeon of the break in technique Where does decontamination begin? - ANSWERS,Starts at the field, with wiping the instruments to keep the bioburden down How many air exchanges does Decontamination area have? - ANSWERS,6 air exchanges per hour What temperature does decontamination area need to be set at? - ANSWERS,68-73 degrees What is the humidity setting for decontamination area? - ANS
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MINIMIZING SURGICAL FIRES: What should you place in the pt&039;s throat for procedures involving the mouth/face/airway and why? What should you inflate the ET tube cuff with and why? - ANSWERS,-saline moistened lap, to assist with decreasing/preventing O2 leaks from tube -tinted saline solution, the liquid helps increase the temp required to rupture the cuff, the color helps visualize a rupture SURGERY IN THE AIRWAY/CHEST AREA: To prevent fire, what should you coat the pt&039;s head/facial hair with? What should you use between the surgical site and O2 source? What should anes suction be used to evacuate? - ANSWERS,-water soluble gel -Ioban incise drape -accumulated anes gas SURGICAL FIRES: What type of fire extinguishers are recommended for OR use?(2) Should you use fire blankets in the OR?-why?(4) When using open source O2, how should the drapes be placed over the head? - ANSWERS,-Water mist and Carbon dioxide -no, they can trap the fire next to/under the pt, they can dislodge instruments, they can cause wound contamination, they can spread the fire -in a way that allows for O2 to flow freely/prevent accumulation under the drape SURGICAL FIRES: What gases are present in the bowel? How should you create an incision in the bowel or trachea? What prevention technique should you use for surgeries near the rectum? What should you use to administer supplemental O2 in pt&039;s that need O2 greater than 30%? When is an environment considered oxygen rich? - ANSWERS,-methane, hydrogen -with a scalpel rather than monopolar cautery -cover or pack the rectum with a wet lap -laryngeal mask airway or ET tube -if the O2 concentration is greater than 21% by volume MEDICAL GASES: where/how should you store med gases in a facility? store separately from? what identifiers are present on med gas cylinders to determine their contents?(3) - ANSWERS,- indoors in a secured access-controlled area with chain like devices to lock and in a holder/on a rack -industrial gases -the color of the cylinder, written labels on the cylinders, the pin index safety system
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Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Feefor-Service (FFS) Medicare? What could you tell him? -CORRECT ANSWER-- Part A, which covers hospital, skilled nursing facility, hospice and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. Mr. Lopez, who is fairly well off, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him? -CORRECT ANSWER-- Enrollees should pay using automatic withdrawal from a bank account or credit or debit card, direct monthly billing from the plan, or deductions from their Social Security check. Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a
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NR 302 Health Assessment I NR 302 Week 2 Practice Quiz (Exam 1 Review Content) 1. Question: After completing an initial assessment of a patient, the nurse has … that his respirations are eupneic and his pulse is 58 beats per minute. What type of assessment data is this? 2. Question: A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of assessment data is this? 3. Question: The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? 4. Question: The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? 5. Question: A newly … patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? 6. Question: During an assessment, the nurse notices that a patient is handling a small charm that is … to a leather strip around his neck. Which action by the nurse is appropriate? 7. Question: The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of a culturally competent caregiver? 8. Question: Which adjustment in the physical environment should the nurse make to promote the success of an interview? 9. Question: The nurse asks, “I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.” Based on this question, the nurse is at which phase of the interview process? 10. Question: During an interview, the nurse states, “You mentioned having shortness of breath. Tell me more about that.” Which verbal skill is … with this statement? 11. Question: A woman is discussing the problems she is having with her 2-year- old son. She says, “He won’t go to sleep at night, and during the day he has several fits. I get so upset when that happens.” Which is the best response by the nurse to gain a better understanding of the problem? 12. Question: A pregnant woman states, “I just know labor will … so painful that I won’t … able to stand it. I know it sounds awful, but I really dread going into labor.” The nurse responds by stating, “Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.” Which statement is true regarding the nurse’s response? 13. Question: The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? 14. Question: A woman brings her husband to the clinic for an examination. She is particularly … because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action? 15. Question: A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first? 16. Question: When performing a physical assessment, what technique should the nurse always perform first? 17. Question: The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should … to best assess the patient’s skin temperature? 18. Question: Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? 19. Question: The nurse is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess? 20. Question: The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? 21. Question: The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? 22. Question: The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next? 23. Question: The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group? 24. Question: Which of these statements is true regarding the use of Standard Precautions in the health care setting? 25. Question: When examining an infant, the nurse should examine which area first? 26. Question: While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should … … to assess this murmur? 27. Question: The nurse is performing a general survey. Which action is a component of the general survey? 28. Question: The nurse is assessing an 80-year-old male patient. Which assessment findings would … normal? 29. Question: The nurse is performing a general survey of a patient. Which finding is … normal? 30. Question: Which of these specific measurements is the best index of a child’s general health? 31. Question: The nurse should measure rectal temperatures in which of these patients? 32. Question: Which technique is correct when the nurse is assessing the radial pulse of a patient? 33. Question: The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child’s respirations? 34. Question: A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” Which is the best reply by the nurse? 35. Question: While measuring a patient’s blood pressure, the nurse should recall that which is a factor that influences a patient’s blood pressure? 36. Question: The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-… blood pressure cuff. How would this likely affect the blood pressure reading? 37. Question: The nurse has … the following information on a patient: … blood pressure–180 mm Hg; … blood pressure– 170/100 mm Hg; apical pulse–60 beats per minute; radial pulse–70 beats per minute. What is the patient’s pulse pressure? 38. Question: When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure? 39. Question: The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? 40. Question: The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? 41. Question: The nurse is counting an infant’s respirations. Which technique is correct? 42. Question: The nurse is evaluating a patient’s pain. Which is an example of acute pain? 43. Question: A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, “It hurts so bad.” Which pain assessment tool would … the best choice when assessing this child’s pain? 44. Question: The nurse is assessing a patient’s pain. What should the nurse know is the most reliable indicator of pain? 45. Question: When assessing the quality of a patient’s pain, the nurse should ask which question? 46. Question: When assessing the intensity of a patient’s pain, which question by the nurse is appropriate? 47. Question: The nurse recognizes which of these people is at greatest risk for undernutrition? 48. Question: For the first time, the nurse is seeing a patient who has no history of nutrition-… problems. Which activity should the initial nutritional screening include? 49. Question: In performing an assessment on a 49-year-old woman who has … nutrition as a result of dysphagia, which data would the nurse expect to find? 50. Question: An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient’s gums are swollen, … and bleeding in some areas. The nurse suspects that the patient has what condition?
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Peracetic acid - ANSWERS,Automated Endoscope Reprocessor (AER) - GI For items that can be immersed Corrosive to instruments and people Temp 120-130 degrees F 20-30 mins Micro filtered tap water rinses x 4 to turn it back to vinegar Must have log Sterilizes using acidity Vinegar with extra hydrogen to make it very acidic Ozone - ANSWERS,low temp sterilization only one manufacturer in the USA FDA has cleared ozone for sterilization of metal and plastic Exhaust is passed through a catalytic converter Environmentally sound No aeration By-products are oxygen and water Dry heat - ANSWERS,High temp Best for heat stable powder and oils Dental instruments, burrs, reusable needles, glassware Don&039;t use tape Common in doctor and dental offices and tattoo parlors 360-400 degrees F 50-60 min run time Specific packaging for this QC - ANSWERS,items should be traceable from method of sterilization Lot, control, load or cycle, date, and time should be documented for each item Required by CDC to track SSIs on certain patients like colons and totals Autoclave QC - ANSWERS,Daily biological (ideally) for gravity displacement and pre-vac Daily Bowie-Dick for pre-vac (1st run is warm up, 2nd run is test, 3rd run is item); uniform pattern indicates that the vac cycle functioned properly Done with every implant Sterilization log required Steam - gravity displacement and prevac testing - ANSWERS,Geobacillus stearothemophilus spore testing at least weekly and preferably daily Pre-vac testing - ANSWERS,Air removal like Bowie-Dick should be done daily in an empty chamber; for new, renovated, or moved equipment, 3 consecutive successful air removal tests should be done before the biological Ethylene oxide testing - ANSWERS,Bacillus atropheus spore testing done with every load Plasma testing - ANSWERS,Geobacillus stearothermophilus spore testing done at same interval as other sterilizers in the facility Ozone and peracetic acid testing - ANSWERS,Geobacillus stearothermophilus daily Dry heat testing - ANSWERS,Bacillus atropheus indicators upon installation and after any repair (table top type monitored weekly) Packaging Sterile Items - ANSWERS,Must work with the type of sterilization Must allow for identification of the contents (writing on the outside) Weight should not exceed 25 lbs Lint free Free of holes Sterile storage areas must not exceed 78 degrees F or 60% humidity Manufacturer&039;s instructions always supersede the guidelines Packaging and Sterilization - ANSWERS,No textiles, peel pouches, or rubber mats inside the tray Instruments disassembled Instruments in open, unlocked position Integrator in corner of tray because that&039;s the hardest for steam to get to Indicator on inside and outside of tray (class 5 indicator inside) Count sheet on outside of trays Inside of sealed envelope is not sterile Integrator on top of tray Peel Pouches - ANSWERS,Not stacked inside of sterilization chamber Write on the plastic, not paper Not for use with heavy items steam only goes through paper side Double pouching - ANSWERS,with manufacturer&039;s instructions onl
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Test Bank for Medical-Surgical Nursing, 7th Edition by Adrianne Dill Linton and Mary Ann Matteson Table of Contents UNIT I: Medical-Surgical Nursing 1. Aspects of Medical-Surgical Nursing 2. Medical-Surgical Practice Settings UNIT II: Populations Receiving Medical-Surgical Care 3. Medical-Surgical Patients: Individuals, Families, and Communities UNIT III: Pathology Processes and Effects 4. Health, Illness, Stress, and Coping 5. Immunity, Inflammation, and Infection 6. Fluid, Electrolyte, and Acid-Base Balance 7. Cancer 8. Pain 9. Shock UNIT IV: Special Problems of the Older Adult Patient 10. The Older Adult Patient 11. Falls 12. Immobility 13. Delirium & Dementia 14. Incontinence UNIT V: Therapeutics 15. Nutrition 16. Intravenous Therapy 17. Surgery 18. Ostomy 19. Palliative and Hospice Care 20. Complementary and Alternative Therapies UNIT VI: Neurological System 21. Neurological System Introduction 22. Neurological Disorders 23. Cerebrovascular Accident 24. Spinal Cord Injury UNIT VII: Respiratory System 25. Respiratory System Introduction 26. Upper Respiratory Disorders 27. Acute Lower Respiratory Disorders 28. Chronic Lower Respiratory Tract Disorders UNIT VIII: Hematologic and Immunologic Systems 29. Hematologic System Introduction 30. Hematologic Disorders 31. Immunologic System Introduction 32. Immunologic Disorders UNIT IX: Cardiovascular System 33. Cardiovascular System Introduction 34. Cardiac Disorders35. Vascular Disorders 36. Hypertension UNIT X: Digestive System 37. Digestive System Introduction 38. Upper Digestive Tract Disorders 39. Lower Digestive Tract Disorders 40. Liver, Gallbladder, and Pancreatic Disorders UNIT XI: Urologic System 41. Urologic System Introduction 42. Urologic Disorders UNIT XII: Musculoskeletal System 43. Musculoskeletal System Introduction 44. Connective Tissue Disorders 45. Fractures 46. Amputations UNIT XIII: Endocrine System 47. Endocrine System Introduction 48. Pituitary and Adrenal Disorders 49. Thyroid and Parathyroid Disorders 50. Diabetes and Hypoglycemia UNIT XIV: Reproductive Systems 51. Female Reproductive System Introduction 52. Female Reproductive Disorders 53. Male Reproductive System Introduction 54. Male Reproductive Disorders 55. Sexually Transmitted Infections UNIT XV: Integumentary Systems 56. Integumentary System Introduction 57. Skin Disorders UNIT XVI: Special Senses 58. Special Senses Introduction 59. Eye and Vision Disorders 60. Ear and Hearing Disorders UNIT XVII: Medical-Surgical Patients with Psychiatric Disorders 61. Psychobiologic Disorders 62. Substance Abuse
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Test Bank for Pediatric Nursing The Critical Components of Nursing Care, 2nd Edition, Kathryn Rudd, Diane KociskoTest Bank for PediatricNursing: The Critical Components of Nursing Care,2nd Edition, Kathryn Rudd, Diane KociskoTable of Contents Pediatric Nursing: An Overview 1. Issues and Trends in Pediatric Nursing 2. Standards of Practice and Ethical Considerations Psycho-Social-Cultural Assessment of the Child and the Family 3. Family Dynamics and Communicating with Children and Families 4. Cultural, Spiritual, and Environmental Influences on the Child 5. End-of-Life Care Growth and Development of the Child 6. Growth and Development 7. Newborns and Infants 8. From Toddlers to Preschoolers 9. School-Age Children 10. Adolescents Common Illnesses or Disorders in Childhood and Home Care 11. Respiratory Disorders 12. Cardiovascular Disorders 13. Neurological and Sensory Disorders 14. Mental Health Disorders 15. Gastrointestinal Disorders 16. Renal disorders 17. Endocrine disorders 18. Reproductive and Genetic Disorders 19. Hematologic, Immunologic, and Neoplastic Disorders 20. Musculoskeletal Disorders 21. Dermatologic Diseases 22. Communicable DiseasesPediatric Nursing The Critical Components of Nursing Care 2nd Edition Rudd Test Bank Chapter 1. Issues and Trends in Pediatric Nursing MULTIPLE CHOICE 1. A nurse is reviewing changes in healthcare delivery and funding for pediatric populations. Which current trend in the pediatric setting should the nurse expect to find? a. Increased hospitalization of children b. Decreased number of uninsured children c. An increase in ambulatory care d. Decreased use of managed care ANS: C One effect of managed care is that pediatric healthcare delivery has shifted dramatically from the acute care setting to the ambulatory setting. The number of hospital beds being used has decreased as more care is provided in outpatient and home settings. The number of uninsured children in the United States continues to grow. One of the biggest changes in healthcare has been the growth of managed care. DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 2. A nurse is referring a low-income family with three children under the age of 5 years to a program that assists with supplemental food supplies. Which program should the nurse refer this family to? a. Medicaid b. Medicare c. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program d. Women, Infants, and Children (WIC) programANS: D WIC is a federal program that provides supplemental food supplies to low-income women who are pregnant or breast-feeding and to their children until the age of 5 years. Medicaid and the Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program provides for wellchild examinations and related treatment of medical problems. Children in the WIC program are often referred for immunizations, but that is not the primary focus of the program. Public Law 99- 457 provides financial incentives to states to establish comprehensive early intervention services for infants and toddlers with, or at risk for, developmental disabilities. Medicare is the program for Senior Citizens. DIF: Cognitive Level: Application REF: p. 7 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 3. In most states, adolescents who are not emancipated minors must have parental permission before: a. treatment for drug abuse. b. treatment for sexually transmitted diseases (STDs). c. obtaining birth control. d. surgery. ANS: D An emancipated minor is a minor child who has the legal competence of an adult. Legal counsel may be consulted to verify the status of the emancipated minor for consent purposes. Most states allow minors to obtain treatment for drug or alcohol abuse and STDs and allow access to birth control without parental consent. DIF: Cognitive Level: Application REF: p. 12 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 4. A nurse is completing a clinical pathway for a child admitted to the hospital with pneumonia. Which characteristic of a clinical pathway is correct? a. Developed and implemented by nursesb. Used primarily in the pediatric setting c. Specific time lines for sequencing interventions d. One of the steps in the nursing process ANS: C Clinical pathways measure outcomes of client care and are developed by multiple healthcare professionals. Each pathway outlines specific time lines for sequencing interventions and reflects interdisciplinary interventions. Clinical pathways are used in multiple settings and for clients throughout the life span. The steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 5. When planning a parenting class, the nurse should explain that the leading cause of death in children 1 to 4 years of age in the United States is: a. premature birth. b. congenital anomalies. c. accidental death. d. respiratory tract illness. ANS: C Accidents are the leading cause of death in children ages 1 to 19 years. Disorders of short gestation and unspecified low birth weight make up one of the leading causes of death in neonates. One of the leading causes of infant death after the first month of life is congenital anomalies. Respiratory tract illnesses are a major cause of morbidity in children. DIF: Cognitive Level: Application REF: p. 9 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 6. Which statement is true regarding the quality assurance or incident report?a. The report assures the legal department that there is no problem. b. Reports are a permanent part of the clients chart. c. The nurses notes should contain the following: Incident report filed and copy placed in chart. d. This report is a form of documentation of an event that may result in legal action. ANS: D An incident report is a warning to the legal department to be prepared for potential legal action; it is not a part of the clients chart or nurse documentation. DIF: Cognitive Level: Knowledge REF: p. 14 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 7. Which client situation fails to meet the first requirement of informed consent? a. The parent does not understand the physicians explanations. b. The physician gives the parent only a partial list of possible side effects and complications. c. No parent is available and the physician asks the adolescent to sign the consent form. d. The infants teenage mother signs a consent form because her parent tells her to. ANS: C The first requirement of informed consent is that the person giving consent must be competent. Minors are not allowed to give consent. An understanding of information, full disclosure, and voluntary consent are requirements of informed consent, but none of these is the first requirement. DIF: Cognitive Level: Comprehension REF: p. 12 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 8. A nurse assigned to a child does not know how to perform a treatment that has been prescribed for the child. What should the nurses first action be? a. Delay the treatment until another nurse can do it. b. Make the childs parents aware of the situation.c. Inform the nursing supervisor of the problem. d. Arrange to have the child transferred to another unit. ANS: C If a nurse is not competent to perform a particular nursing task, the nurse must immediately communicate this fact to the nursing supervisor or physician. The nurse could endanger the child by delaying the intervention until another nurse is available. Telling the childs parents would most likely increase their anxiety and will not resolve the difficulty. Transfer to another unit delays needed treatment and would create unnecessary disruption for the child and family. DIF: Cognitive Level: Application REF: p. 11 OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment 9. A nurse is completing a care plan for a child and is finishing the assessment phase. Which activity is not part of a nursing assessment? a. Writing nursing diagnoses b. Reviewing diagnostic reports c. Collecting data d. Setting priorities ANS: D Setting priorities is a part of planning. Writing nursing diagnoses, reviewing diagnostic reports, and collecting data are parts of assessment. DIF: Cognitive Level: Comprehension REF: p. 19 OBJ: Nursing Process Step: Planning MSC: Physiological Integrity 10. Which patient outcome is stated correctly? a. The child will administer his insulin injection before breakfast on 10/31. b. The child will accept the diagnosis of type 1 diabetes mellitus before discharge.c. The parents will understand how to determine the childs daily insulin dosage. d. The nurse will monitor blood glucose levels before meals and at bedtime. ANS: A The outcome is stated in client terms, with a measurable verb and a time frame for action. The verb accept is difficult to measure. The goal of accepting a diagnosis before hospital discharge is unrealistic. Outcomes should be stated in client terms. Nursing actions are determined after outcomes are developed in the implementation phase of the nursing process. DIF: Cognitive Level: Application REF: p. 20 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment MULTIPLE RESPONSE 1. A nurse is reviewing the nursing care plan for a hospitalized child. Which statements are collaborative problems? Select all that apply. a. Risk for injury b. Potential complication of seizure disorder c. Altered nutrition: Less than body requirements d. Fluid volume deficit e. Potential complication of respiratory acidosis ANS: B, E In addition to nursing diagnoses, which describe problems that respond to independent nursing functions, nurses must also deal with problems that are beyond the scope of independent nursing practice. These are sometimes termed collaborative problemsphysiological complications that usually occur in association with a specific pathological condition or treatment. The potential complications of seizure disorder and respiratory acidosis are physiological complications that will require physician collaboration to treat. Risk for injury, altered nutrition, and fluid volume deficit will respond to independent nursing functions.DIF: Cognitive Level: Application REF: p. 20 OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment 2. Which nursing activities do not meet the standard of care? Select all that apply. a. Failure to notify a physician about a childs worsening condition b. Calling the supervisor about staffing concerns c. Delegating assessment of a new admit to the Unlicensed Assistive Personnel (UAP) d. Asking the Unlicensed Assistive Personnel (UAP) to take vital signs e. Documenting that a physician was unavailable and the nursing supervisor was notified ANS: A, C A nurse who fails to notify a physician about a childs worsening condition and delegating the assessment of a new admit to a UAP do not meet the standard of care. Calling the supervisor about staffing concerns, asking the UAP to take vital signs, and documenting that a physician could not be reached and the nursing supervisor was notified all meet the standard of care. Chapter 2. Standards of Practice and Ethical Considerations Multiple Choice 1. Leah is a new graduate nurse and has questions about her scope of practice. The best place to review would be: 1. The code of ethics. 2. The standards of practice and professional performance. 3. The NCLEX exam. 4. The state licensing body. ANS: 2Feedback 1.Applies to the accountability and protection for the public 2.Benchmark for quality and accountability to provide professional guidance 3.This is the basic exam, but it does not give guidance on this matter. 4.The state has rules and regulations, but it is not the source for overall professional accountability and guidance. 2. The Code of Ethics for Nurses is characterized by all of the following except: 1. It serves as a guide to empower individuals. 2. It upholds ethics, principles, rights, duties and virtues. 3. It is a private statement for nurses only. 4. It is a public statement for nurses and their patients. ANS: 3 Feedback 1.Part of the Code of Ethics 2.Part of the Code of Ethics 3. The Code of Ethics is not a private statement. It is for the public and nurses. 4. Part of the Code of Ethics 3. A nurse has discussed the plan of care, asked for parental input, and has spoken with the doctor about the needs of the family and patient. This nurse is exhibiting which characteristics of therapeutic relationships in pediatric medicine? 1. Goals, mutual respect/trust, and advocacy 2. Empowerment, sympathy, and empathy3. Goals, advocacy, and sympathy 4. Respect/trust, disengagement, and sympathy ANS: 1 Feedback 1. The nurse is demonstrating all characteristics listed. 2. The nurse is not demonstrating sympathy or empathy for the patient. 3.The nurse is not demonstrating sympathy for this family. 4.The nurse is not disengaging or providing sympathy for the family. 4. A primary source for the standards of practice for pediatric nurses is: 1. Pediatric Nursing Scope and Standards of Practice. 2. Code of Ethics. 3. Nightingales Pledge. 4. None of the above. ANS: 1 Feedback 1. Reflects key themes and trends that are relevant to our time and to all pediatric health care settings, which provide the framework for the emergence of specific standards. 2. The Code of Ethics in Nursing provides a foundation for nurses and empowers them as well. 3. The pledge was part of the early Hippocratic Oath. 4.One answer is correct. 5. Sarah is a 4-year-old patient with cystic fibrosis. She has been having increased hospitalizations and prefers to have Leah as her nurse as an inpatient. Leah has been assigned to care for a different set of patients today, yet Sarahs mother insists on having Leah as their nurse. Which action wouldbe best for Leah to take with Sarah and her mother? 1. Ignore the situation. 2. Speak to Sarah and her mother to discuss the importance of having another nurse, who also knows the case, care for her. 3. Let Sarahs mother and Sarah voice their reasoning for wanting Leah, and then explain the need for Leah to have a different assignment. 4. Let the charge nurse deal with the situation. ANS: 3 Feedback 1.Ignoring the situation does not demonstrate therapeutic communication. 2.Speaking with the family is important, but letting the family voice their concerns is important as well. 3. The dialogue between the patient and nurse can enhance trust and understanding so the patient can understand the situation. 4. The charge nurse may be part of the conversation, but it is important for Leah to speak too. 6. Which of the following situations would be considered a therapeutic communication challenge in pediatric nursing? 1. 1. A street-smart teenager 2. 2. A noncompliant patient and family 3. 3. A culture that the nurse has not been previously exposed to 4. 4. All of the above ANS: 4 Feedback 1.Considered a therapeutic communication challenge in pediatric nursing 2.Considered atherapeutic communication challenge in pediatric nursing 3.Considered a therapeutic communication challenge in pediatric nursing 4.All fit the criteria 7. The purpose of a Child Life Department for Family-Centered Care is: 1. To prepare the child for procedures. 2. To offer time to be a kid. 3. To provide the staff with information about child development. 4. To be the liaison between the hospital and the school system for a child. 5. 1, 2, 4 ANS: 5 Feedback 1. Preparation is an important element in caring for a child. It helps reduce anxiety and promotes a trusting relationship. 2. Playtime allows a child to cope and fosters self-expression, which reduces stress. 3. CLD is knowledgeable in child development and is present to support the child and the family, not the staff. 4. CLD provides a working relationship between the hospital and school for patients who are in the hospital long term. 5. Preparation is an important element in caring for a child. It helps reduce anxiety and promotes a trusting relationship. Playtime allows a child to cope and fosters self-expression, which reduces stress. CLD provides a working relationship between the hospital and school for patients who are in the hospital long term. 8. A nurse is discussing pain management of a 3 year-old with the parents. An important factor the nurse should mention is: 1. A child is like a mini-adult, so they cope with pain the same way.2. Effective pain management for a child may require pharmacological and nonpharmacological methods. 3. Children use the pain scale of 0-10. 4. Pain is subjective, and all children cry when they are in pain. ANS: 2 Feedback 1. Children have a unique response to pain. 2. Pharmacological methods may work for children, but using non- pharmacological methods, such as distraction, are also beneficial. 3. Common pain scales for children consist of the FLACC and NAP. 4.Pain is subjective, but not all children will cry. Some will be irritable or withdrawn. 9. A 6-year-old boy is to receive a dose of morphine to aid in pain management after an open appendectomy. The nurse knows the correct dose for the morphine is calculated based on: 1. Age. 2. Height. 3. Body weight. 4. All of the above. ANS: 3 Feedback 1. Age is not a factor in drug calculation. 2. Height is not a factor in drug calculation.3. Body weight is used for drug calculation. 4. Age and height do not affect drug calculation. 10. A nurse at the clinic is teaching a new mother how to give Tylenol drops to her infant. The nurse knows that the mother has an understanding of medication administration when the mother states: 1. I will give the medication as prescribed and use a teaspoon to measure the correct amount. 2. I will use a syringe to measure the correct amount and place the syringe in the side of his cheek to take the medicine. 3. I will measure the medication in a cup and place it into the bottle. 4. I will make sure he only takes the medicine until he acts like he feels better. ANS: 2 Feedback 1.A teaspoon does not give an accurate measurement for childrens medication. 2.A syringe is the best option for medication administration. Placing it in the side of the cheek enables the infant to swallow without choking. 3. This method does not ensure that the child received all the medication, especially if the entire bottle is not consumed. 4. Medication should be taken for as long as the doctor has ordered. 11. The public health nurse is working on new printed material for the pediatric clinic. The public health nurse decides more education needs to be provided on nutritious snacks for children 5 to 10 years of age. In the design process of the pamphlets, it is important for the public health nurse to: 1. Provide information at an educational level no higher than 8th grade. 2. Provide information at an education level no higher than 12th grade.3. Provide the material in an easy manner, using acronyms to keep the pamphlet small. 4. Provide information in small print and place the pamphlet in open areas for people to take freely. ANS: 1 Feedback 1.Information should be at the 8th grade level or lower. 2.Information should be at 8th grade level or lower. 3.Acronyms may give different ideas than what the material is stating. 4.Allowing for people to take freely is good, but small print can deter someone from reading the information. Bold and bright print is best. 12. A pediatric clinic nurses main responsibilities include: 1. Assessing parenting styles. 2. Assessing readiness to learn for the patient and family. 3. Documentation of family and parental responses to education. 4. Assessing the culture of the family. 5. All of the above. 6. None of the above. ANS: 5 Feedback 1. It is a responsibility along with others. 2. It is a responsibility along with others. 3. It is a responsibility along with others.4. It is a responsibility along with others. 5. Correct because all are responsibilities of the nurse. 6. One answer is correct. 13. Grant, who is 16, is at the pediatric clinic for his yearly checkup. The nurse requests that his father step out of the patient room because: 1. Grants father is not providing information the nurse needs. 2. Grant appears apprehensive with his father in the room. 3. Grant has a right to confidentiality to discuss his use of alcohol. 4. Privacy is not appropriate for this age range, and the father should remain in the room. ANS: 3 Feedback 1. Confidentiality is appropriate due to Grants age. 2. The question does not give information about the interaction between Grant and his father. 3. Privacy about topics such as substance use is appropriate for this age range. 4. Grant has a right to confidentiality due to his age. 14. A medical chaperone is advisable for a 14-year-old girl when: 1. Having an exam of the breasts. 2. Having an eye exam. 3. Having a hearing screen. 4. Having her height and weight taken. ANS: 1Feedback 1.A medical chaperone should be present because of the invasiveness of the procedure. 2.A medical chaperone is recommended, but not a necessity. 3.A medical chaperone is recommended, but not a necessity. 4.A medical chaperone is recommended, but not a necessity. 15. A 9-year-old has come to the nurses office at the school complaining of arm pain. The nurse examines the arm and notices fingertip bruises on the forearm, as if it has been squeezed tightly. The nurse talks to the child about how the arm got the bruises. The next action the school nurse should take is: 1. Report this to the classroom teacher, principal, and Child Protective Services since it is a questionable mark on the forearm. 2. Let the child go back to the classroom since this is a normal bruising pattern that children get at this age through play. 3. Let the child go back to the classroom since the child explains that the bruises came from a game of tag. 4. Document the bruising and follow up with the child in two days to make sure it is healing. ANS: 1 Feedback 1. The nurse is a mandatory reporter and should speak with the people listed because bruising like this is abnormal for a child. 2. This is an abnormal bruising pattern for child. 3.Documentation and notification should occur because this is an abnormal bruising pattern for a child. 4.Documentation and notification should occur because this is an abnormal bruising pattern for a child.16. Ali is a new graduate nurse and has been working on the nursing unit for six months. Ali has noticed that the nurses station attempts to keep patient information confidential. Which of the following actions are not good practices for maintaining confidentiality? 1. Placing the patient chart upside down on the desk when not in use so the name is not revealed. 2. Speaking of patients by room number, not by name. 3. Staying logged onto a computer to answer a call light. 4. Removing patient identifiers on a medication bottle and throwing it into the garbage can. ANS: 3 Feedback 1.This is a good practice for confidentiality. 2.This is a good practice for confidentiality. 3. This allows for anyone to see the computer information about a patient, thus breaking confidentiality. 4. This is a good practice for confidentiality. 17. HIPAA requires health-care providers and employees to be cognizant of: 1. Placement of computer screens to the public. 2. Where discussions about patients occur. 3. How and where change of shift reports occur. 4. All of the above are areas to keep confidential. ANS: 4 Feedback1.Follows HIPAA confidentiality along with others. 2.Follows HIPAA confidentiality along with others. 3.Follows HIPAA confidentiality along with others. 4.Computer screens, discussions, and change of shift reports should be kept confidential to follow HIPAA guidelines. 18. Jake, a 14-year-old terminal leukemia patient, has told his parents and his health-care providers that he no longer wants to take chemotherapy treatments. The nurse knows that Jake: 1. Can make this decision because he is of legal medical age. 2. Is not of legal age to make a medical decision. This is an ethical decision that must be discussed only with Jakes parents. 3. Must discuss this ethical issue with his parents. 4. Is not of legal age to make a medical decision, thus he has not right to determine his care. ANS: 3 Feedback 1. Jake is not of legal age to make a medical decision, but he is of an age where he is aware of his body and the medical teams actions. 2. Jake should be a part of the discussion because he is at an age where he is aware of his body and medical needs. 3. Jake and his parents should make the decision together. 4. Jakes parents have medical power of attorney, but he is at an age where his wants and needs should be taken into consideration. 19. JoJo, a 10-year-old patient in room 1232 with a right arm and leg amputation due to osteosarcoma, has been refusing help with his daily routine. JoJo is exhibiting: 1. Beneficence.2. Justice. 3. Veracity. 4. Autonomy. ANS: 4 Feedback 1. This is an act for a nurse to do good, not harm a patient. 2. This is the obligation for caring for the patient. 3. This is the act of telling the patient the truth. 4. This is an act of exhibiting the need to do things by oneself. 20. A home-care pediatric nurse is taking care of an immobile three year old with a home ventilator. The nurse knows she must maintain proper positioning for the child in order to prevent bedsores from developing. This knowledge is known as: 1. Justice. 2. Beneficence. 3. Veracity. 4. Fidelity. ANS: 2 Feedback 1. This is the obligation for caring for the patient. 2. This is an act for a nurse to do good, not harm a patient. 3.This is the act of telling the patient the truth. 4.This is a nurses responsibility for providing the best care possible for the patient.Chapter 3. Family Dynamics and Communicating with Children and Families MULTIPLE CHOICE 1. A nurse is teaching parents how to apply time-out as a disciplinary method for their 4 year old. Parents have understood the teaching if they state which formula correctly guides the use of timeout? a. Use the guideline of 1 minute per each year of the childs age. b. Relate the length of the time-out to the severity of the behavior. c. Never use time-out for a child younger than age 4 years. d. Follow the time-out with a treat. ANS: A In time-out, the child is told to sit on a chair for a predetermined time, usually 1 minute per year of age. Relating time to a behavior is subjective and inappropriate when the child is very young. Time-out can be used with a toddler. Negative behavior should not be reinforced with a positive action. DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance 2. What is the nurses best approach when an 8-year-old boy frequently causes a disruption in the playroom by taking toys from other children? a. Exclude the child from the playroom. b. Explain to the children in the playroom that he is very ill and should be allowed to have the toys. c. Approach the child in his room and ask, Would you like it if the other children took your toys from you?d. Approach the child in his room and state, I am concerned that you are taking the other childrens toys. It upsets them and me. ANS: D The nurse can focus on the behavior most effectively by using I rather than you messages. A you message criticizes the child and uses guilt in an attempt to change behavior. Banning the child from the playroom will not solve the problem. The problem is the childs behavior, not the place where the child exhibits it. Illness is not a reason for a child to be undisciplined. When the child recovers, the parents will have to deal with a child who is undisciplined and unruly. The child should not be made to feel guilty and to have his or her self-esteem attacked. DIF: Cognitive Level: Application REF: p. 34 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 3. Families that deal most effectively with stress have which behavior patterns? a. Focus on family problems. b. Feel weakened by stress. c. Expect that some stress is normal. d. Feel guilty when stress exists. ANS: C Healthy families recognize that some stress is normal in all families, focus on family strengths rather than on the problems, and know that stress is temporary and may be positive. Because some stress is normal in all families, there is no reason to feel guilty. Guilt only immobilizes the family and does not lead to a resolution of the stress. DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity4. Which family will most likely have the greatest difficulty in coping with an ill child? a. A single-parent mother who has the support of her parents and siblings b. Parents who have just moved to the area and are living in an apartment while they look for a house c. The family of a child who has had multiple hospitalizations related to asthma and has adequate relationships with the nursing staff d. A family in which there is a young child and four older married children who live in the area ANS: B Parents who are in a new environment will have increased stress related to their lack of a support system. If only one parent is available but has the support of her extended family, this will assist in her adjustment to the crisis. The family that has had positive experiences in the past with hospitalizations can draw from those experiences and feel confident about the current setting. For the family with one younger child and four older married children who live in the area, the family has an extensive support system, which will assist the parents in adjusting to the crisis. DIF: Cognitive Level: Application REF: p. 27 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 5. Which is the priority nursing intervention for the family of a child who has been admitted to the hospital? a. Begin discharge teaching. b. Identify and mobilize internal and external strengths. c. Identify ways in which the family could have prevented their childs hospitalization. d. Instruct the parents on normal growth and development. ANS: BFamily interventions should be directed toward enhancing positive coping strategies and directing the family to appropriate resources. Although discharge teaching is begun as soon as possible, it is ineffective if trust has not been established with the parents or if the level of stress precludes learning. By identifying weaknesses instead of focusing on strengths, the familys anxiety and feelings of powerlessness or guilt may increase. Normal growth and development should be interwoven into teaching; however, teaching cannot take place until the parents have less stress and are open to information. DIF: Cognitive Level: Application REF: p. 27 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 6. A nurse is planning culturally competent care for a child of Hispanic descent. Which characteristic found in a Hispanic family should the nurse include in the plan of care? a. Stoicism b. Close extended family c. Docile children are considered weak d. Very interested in health-promoting lifestyles ANS: B Most Mexican-American families are very close and it is not unusual for children to be surrounded by parents, siblings, grandparents, and godparents. It is important to respect this cultural characteristic and to see it as a strength, not a weakness. Although stoicism may be present in any family, Mexican-American families tend to be more expressive. Considering docile children as weak is a characteristic of American Indians. Although there is a trend for everyone to embrace more health-promoting lifestyles, it is more prominent in Anglo- Americans. DIF: Cognitive Level: Application REF: p. 28 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity7. While reviewing nursing documentation on dietary intake for a 7-year-old child of Asian descent, the nurse notes that he consistently refuses to eat the food on his tray. Which assumption is most likely accurate? a. He is a picky eater. b. He needs less food because he is on bed rest. c. He may have culturally related food preferences. d. He is probably eating between meals and spoiling his appetite. ANS: C When cultural differences are noted, food preferences should always be obtained. A child will often not eat unfamiliar foods. Although the child may be a picky eater, the key point is that he is from a different culture. The foods he is being served may seem strange to him. Nutrition plays an important role in healing. Although the child expends less energy while on bed rest, he has increased needs for good nutrition. Although it should be determined whether the child is eating food the family has brought from home, it is more important to determine his food preferences. DIF: Cognitive Level: Application REF: p. 28 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 8. To resolve family conflict, it is necessary to have open communication, accurate perception of the problem, and a(n): a. intact family structure. b. arbitrator. c. willingness to consider the view of others. d. balance in personality types. ANS: C Without the willingness of the members of a group to consider the views of others, conflictresolution cannot take place. The structure of a family may affect their dynamics, but it is still possible to resolve conflict without an intact family structure if all the ingredients of conflict resolution are present. Conflicts can be resolved without the assistance of an arbitrator. Most families have diverse personality types among their members. This may make conflict resolution more difficult; however, it should not impede it if the ingredients of conflict resolution are present. DIF: Cognitive Level: Knowledge REF: p. 27 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 9. A nurse is planning a parenting class for expectant parents. Which statement is true about the characteristics of a healthy family? a. The parents and children have rigid assignments for all the family tasks. b. Young families assume total responsibility for the parenting tasks, refusing any assistance. c. The family is overwhelmed by the significant changes that occur as a result of childbirth. d. Adults agree on the majority of basic parenting principles. ANS: D A trait of a healthy family is that adults agree on the basic principles of parenting so that minimal discord exists. A significant stressor for families is lack of shared responsibility in the family. Lack of flexibility in parental tasks is likely to create stress and conflict. Admitting to and seeking help with problems, rather than refusing assistance, is a trait of a healthy family. Adjusting to the birth of a child is a significant change for a family. A sense of feeling overwhelmed by this change indicates that the family is not coping effectively. DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 10. A nurse determines that a child consistently displays predictable behavior and is regular in performing daily habits. Which temperament is the child displaying?a. Easy b. Slow-to-warm-up c. Difficult d. Shy ANS: A Children with an easy temperament are even tempered, predictable, and regular in their habits. They react positively to new stimuli. A high activity level and adapting slowly to new stimuli are characteristics of a difficult temperament. The slow-to-warm-up temperament type prefers to be inactive and moody. Shyness is a personality type and not a characteristic of temperament. Being moody is a characteristic of a slow-to-warm up temperament. DIF: Cognitive Level: Analysis REF: p. 33 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 11. The parent of a child who has had numerous hospitalizations asks the nurse for advice because her child has been having behavior problems at home and in school. In discussing effective discipline, which is an essential component? a. All children display some degree of acting out and this behavior is normal. b. The child is manipulative and should have firmer limits set on her behavior. c. Use positive reinforcement and encouragement to promote cooperation and the desired behaviors. d. Underlying reasons for rules should be given and the child should be allowed to decide on which rules should be followed. ANS: C Using positive reinforcement and encouragement to promote cooperation and desired behaviors is one of the three essential components of effective discipline. Behavior problems should not be disregarded as normal. It would be incorrect to assume the child is being manipulative and should have firmer limits set on her behaviors. Providing the underlying reasons for rules and giving the child a choice concerning which rules to follow constitute a component of permissive parenting and are not considered an essential component of effective discipline.DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 12. A nurse assesses that parents discuss rules with their children when the children do not agree with the rules. Which style of parenting is being displayed? a. Authoritarian b. Authoritative c. Permissive d. Disciplinarian ANS: B A parent who discusses the rules with which children do not agree is using an authoritative parenting style. A parent who expects children to follow rules without questioning is using an authoritarian parenting style. A parent who does not consistently enforce rules and allows the child to decide whether he or she wishes to follow rules is using a permissive parenting style. A disciplinarian style would be similar to the authoritarian style. 13. Which information should the nurse include when preparing a 5-year-old child for a cardiac catheterization? a. A detailed explanation of the procedure b. A description of what the child will feel and see during the procedure c. An explanation about the dye that will go directly into his vein d. An assurance to the child that he and the nurse can talk about the procedure when it is over ANS: B For a preschooler, the provision of sensory information about what to expect during the procedure will enhance the childs ability to cope with the events of the procedure and will decrease anxiety. Explaining the procedure in detail is probably more than the 5-year-old child can comprehend andit will produce anxiety. Using the word dye with a preschooler can be frightening for the child. The child needs information before the procedure. DIF: Cognitive Level: Application REF: pp. 44-45 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 14. Who are the experts in planning for the care of a 9-year-old child with a profound sensory impairment who is hospitalized for surgery? a. The childs parents b. The childs teacher c. The case manager d. The primary nurse ANS: A The parents, as primary caregivers, can identify the childs needs to help develop an effective, individualized plan of care. The childs teacher is not as expert as the childs parents for planning her care. The case manager is not as aware as the parents are of the childs individual needs. The primary nurse would use the childs parents as resources in planning the best approach to the childs care. DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 15. Which is an effective technique for communicating with toddlers? a. Have the toddler make up a story from a picture. b. Involve the toddler in dramatic play with dress-up clothing. c. Repeatedly read familiar stories to the child. d. Ask the toddler to draw pictures of his fears.ANS: C Ritualism is a characteristic of the toddler period. By repeating familiar stories and other rituals, the toddler feels a sense of control, which facilitates communication. Most toddlers do not have the vocabulary to make up stories. Dramatic play is associated with older children. Toddlers probably are not capable of drawing or verbally articulating their fears. DIF: Cognitive Level: Application REF: p. 44 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 16. What is the most important consideration for effectively communicating with a child? a. The childs chronological age b. The parentchild interaction c. The childs receptiveness d. The childs developmental level ANS: D The childs developmental level is the basis for selecting the terminology and structure of the message most likely to be understood by the child. The childs age may not correspond to the developmental level; therefore, it is not the most important consideration for communicating with children. Parentchild interaction is useful in planning communication with children, but it is not the primary factor in establishing effective communication. The childs receptiveness is a consideration in evaluating the effectiveness of communication. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 17. Which behavior is most likely to encourage open communication? a. Avoiding eye contactb. Folding arms across the chest c. Standing with head bowed d. Soft stance with arms loose at the side ANS: D A swaying body with arms loose at the sides suggests openness. Avoiding eye contact does not facilitate communication. Folding arms across the chest and standing with head bowed are closedbody postures, which do not facilitate communication. DIF: Cognitive Level: Comprehension REF: pp. 39-40 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 18. Which strategy is most likely to encourage a child to express feelings about the hospital experience? a. Asking close-ended questions b. Asking direct questions c. Sharing personal experiences d. Actively listening ANS: D Active listening encourages conversation. Direct questions and close-ended questions can threaten and block communication. Talking about yourself shifts the focus of the conversation away from the child. DIF: Cognitive Level: Application REF: p. 38 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 19. Which is the most appropriate question to ask to encourage conversation when interviewing an adolescent?a. Are you in school? b. Are you doing well in school? c. How is school going for you? d. How do your parents feel about your grades? ANS: C Open-ended questions encourage communication. Direct questions with yes or no answers do not encourage conversation. Direct questions that can be interpreted as judgmental do not enhance communication. Asking adolescents about their parents feelings may block communication. DIF: Cognitive Level: Application REF: p. 45 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 20. What is the most appropriate response for the nurse to make to the parent of a 3-year-old child found in a bed with the side rails down? a. You must never leave the child in the room alone with the side rails down. b. I am very concerned about your childs safety when you leave the side rails down. The hospital has guidelines stating that side rails need to be up if the child is in the bed. c. It is hospital policy that side rails need to be up if the child is in bed. d. When parents leave side rails down, they might be considered as uncaring. ANS: B To express concern and then choose words that convey a policy is appropriate. Framing the communication in the negative does not facilitate effective communication. Stating a policy to parents conveys the attitude that the hospital has authority over parents in matters concerning their children and may be perceived negatively. No statement should convey blame and judgment to the parent.Chapter 4. Cultural, Spiritual, and Environmental Influences on the Child Multiple Choice 1. Elsa is working with an 11-year-old patient in the outpatient pediatric clinic. As Elsa reviews the chart, she reads that the patient follows the Muslim tradition. When Elsa enters the room, she notes that the child is wearing a hijab on her head. Elsa has never worked with this tradition before. Elsa should: 1. Realize that her verbal and non-verbal communication will impact the care she gives the child. 2. Not ask the parent for input on the care of the child because this would disrespect the family and child. 3. Have another nurse, who has experience with this culture, take care of the patient. 4. Realize that the patient is uncomfortable and seek a fellow nurse to help her. ANS: 1 Feedback 1. Verbal and non-verbal communication differs in each culture, thus this must be taken into consideration when working with the child. 2. The lack of communication with the parent and child is not therapeutic for the child. 3. Another nurse may be beneficial, but since Elsa has already started caring for the child, this may create problems. 4. There is no indication of the patient feeling uncomfortable. 2. A pediatric nursing class has been assigned to use the Giger and Davidhizar Transcultural Assessment Model. The students are assigned to families they do not have a prior relationship with. When performing the assessment, one of the students is given a seat in close proximity to a grandmother on the couch. The student should know that according to this model: 1. Visiting a family is considered a privilege.2. It is important to identify the family lifestyle. 3. Sitting close to the grandmother can affect the communication. 4. Only the interpersonal relationships of the individuals are emphasized. ANS: 3 Feedback 1. Does not address the economic standing of the family 2. Does not identify a lifestyle 3. Space is a component of the model. 4. Views the familys interactions with society 3. A staff educational day has been planned for the pediatric unit of a major hospital. The goal is to make the staff culturally competent. This is important because: 1. This competency meets JCAHO requirements. 2. This competency meets cultural care requirements for the hospital system. 3. This allows nurses to tailor their care to the patient and provide holistic care. 4. This education is needed to reach Magnet status. ANS: 3 Feedback 1. Not the purpose of the goal 2. Can be a purpose of the hospital, but does not take precedence over the patient. 3. Important to view the patient holistically in order to provide quality care 4.Not the purpose of the goal4. Hussains parents have a language barrier with the nursing staff on the pediatric floor. When working with communication barriers, it is important to: 1. Use pictures when an interpreter is not available. 2. Use hand gestures to attempt to communicate. 3. Ask the interpreter to speak to the family over the phone. 4. Require the family to provide a family member to interpret. ANS: 1 Feedback 1.This is appropriate if there are pictures for the conversation. 2.Each culture is sensitive to body language. Avoid using gestures because this may offend the family. 3. Speaking over the phone can cause communication breakdown, which will not be effective for the conversation. 4. It is a responsibility of the hospital to provide an interpreter for the patient. 5. Social skills between different cultures are important for a pediatric nurse to understand. All of the following are part of social skills except: 1. Personal space. 2. Eye contact. 3. Diet. 4. Exercise. ANS: 4Feedback 1. Influences social skills of cultures 2. Influences social skills of cultures 3. Influences social skills of cultures 4. Not an influence of social skills of cultures 6. The community pediatric nurse is conducting a home visit with a new family. The nurse knows when she is in the home, it will be important to get a thorough assessment. The assessment should consist of: 1. The number of family members living in the home. 2. The employment of the adults in the home. 3. How personal space is perceived. 4. All of the above should be considered in the assessment. ANS: 4 Feedback 1.An important component, along with other choices 2.An important component, along with other choices 3.An important component, along with other choices 4.Family members, employment, and personal space should all be assessed by the nurse. 7. Culturally competent care includes: 1. 1. Treating others exactly how you would like to be treated. 2. 2. Seeing individuals as unique. 3. 3. Treating individuals within the same cultural group the same. 4. 4. Providing care without concern of your own values. ANS: 2Feedback 1.This is important to understand the cultural norms and values 2.Cultural competence includes treating individuals as unique beings. 3.Not all cultural groups follow the same norms and values. 4.Realization of personal values enables the nurse to be culturally competent. 8. A nurse is caring for a 12-year-old patient who has recently been hospitalized. Which statement by the patient proves that the nurse did not perform a complete cultural assessment? 1. Im glad that my prayer times work around my care. 2. I feel better when my mom stays with me. 3. Im not allowed to eat pork, and it is on my lunch tray. 4. My mom does not like it when my room is messy. ANS: 3 Feedback 1.The nurse has planned care to allow for prayer time for the patient. 2.The nurse understands the importance of family. 3. The nurse should have assessed dietary restrictions for the patient and ensured a proper diet is brought to the patient. 4. Family values play a role in the cultural practice of the family. 9. Pediatric visitations should: 1. 1. Be 24 hours a day for parents and grandparents. 2. 2. Be semi-structured for other visitors. 3. 3. Provide time for socialization and playing. 4. 4. All of the above. ANS: 4Feedback 1.Family-centered care is important to the healing process for the child. 2.Visits should be structured in order to allow the child time to rest. 3. Play helps decrease stress for the child. 4. All of the above statements should be included in visitations. 10. A nurse promotes family-centered care when: 1. 1. Caregivers can room in and provide care to their child. 2. 2. The nurse provides the care as the physician orders. 3. 3. Care is provided after the family steps out of the room. 4. 4. Visitation guidelines are strictly followed. ANS: 1 Feedback 1. Including the family in providing care is being family centered. 2. The family needs to be involved in the care in order for it to be family centered. 3. Care should be provided continuously and hold the needs of the family and patient as a high priority. 4. Visitation guidelines are set by the family, not the staff. 11. When utilizing an interpreter, which item does not need to be documented? 1. 1. Name of the individual interpreting 2. 2. Primary language of the patient and caregiver 3. 3. Pictures used to communicate an idea 4. 4. Understanding of the patient and the care provider ANS: 3 Feedback 1. The name must be provided to verify who is giving the information.2. The primary language documentation will provide future workers with information to help the patient. 3. If an interpreter is being used, pictures may only supplement the discussion. The interpreter should be communicating the health-care providers explanations word-for-word. 4. Clarity of the information provided through the interpreter should be documented to identify if the family is understanding the information provided. 12. A nursing student understands pediatric cultural and dietary needs when she tells the parent of her patient: 1. 1. You can bring in food from home. 2. 2. The hospital food should be adequate. 3. 3. I dont know how the food is prepared. 4. 4. Food from home will only make your child miss home. ANS: 1 Feedback 1. Food from home will comfort the child and help him/her understand the types of food that are seen as healthy choices in a time of illness. 2. Hospital food may not be prepared in the proper manner for consumption by some cultures. 3. Learning how the food is prepared will enable the staff to provide for the needs of the child. 4. Children will eat food that is familiar to them and is in compliance with their cultural and spiritual needs. 13. Staff education should include: 1. 1. Education on cultures common to their practice. 2. 2. Annual updates and reviews. 3. 3. Self-reflection on the care providers own values and beliefs. 4. 4. All of the above. ANS: 4Feedback 1. Education should provide information about cultures the staff is not exposed to frequently. 2. Updates and reviews will allow staff to identify the needs of the patients on a continuous basis. 3. Self-reflection will identify biases and how not to let them interfere with the care provided to the patient. 4. All of the above answers should be included in staff education. 14. Spiritual assessments should be performed: 1. 1. During every contact with health-care providers. 2. 2. During hospitalizations. 3. 3. Annually. 4. 4. As needed. ANS: 1 Feedback 1. Spiritual assessments should be conducted during every contact with health-care providers. This would include well-child visits. 2. May need to know this information for immunizations and at well-child checkups. 3. Should be done at each visit in case the situation has changed for the patient. 4. Needs to be performed at every visit to identify changes in the spiritual needs. 15. Effective communication can be confirmed when: 1. 1. The patient or caregiver asks questions. 2. 2. When the patient and caregiver do not verbalize questions. 3. 3. The receiver of the messages understands the information as the provider intended the message to be received. 4. 4. The receiver of the message speaks the same language as the person giving the message.ANS: 3 Feedback 1.Questions are asked to verify information and gather more information. 2.The patient and caregiver may need time to think about information before asking questions. 3. Effective communication entails understanding the message that the sender intended for the receiver. 4. The language does not determine the understanding of the patient or caregiver. 16. When performing an initial assessment, the FICA Spiritual Assessment tool will: 1. 1. Help the care provider to include spiritual needs in the care plan. 2. 2. Will complete the questionnaire in the chart. 3. 3. Be answered by the parent or care provider. 4. 4. Only be answered by the patient. ANS: 1 Feedback 1. The FICA tool assesses faith, importance, community, and addresses care needs within the care plan. 2. Information will be gathered, but should not be the basis of the history or the care. 3. The child should be allowed to have input. 4. The family will have an influence on the spiritual care of the child. 17. An example of a nurse-patient relationship would be: 1. 1. Attending a birthday party outside of the hospital. 2. 2. Providing special toys for favorite patients. 3. 3. Reporting suspected child abuse. 4. 4. Keeping a secret about suspected child abuse to keep confidentiality with the patient.ANS: 3 Feedback 1.The birthday party is beyond the professional boundaries of a nurse. 2.Demonstrating favoritism is not a professional action a nurse should display. 3.Nurses must report actual or suspected child abuse. 4.A nurse is a mandatory reporter and must report any suspicions of child abuse. 18. The medical clinics staff ensures quality multidisciplinary care by: 1. 1. Following hospital policies. 2. 2. Documenting and sharing all information. 3. 3. Not questioning other disciplines. 4. 4. Utilizing the correct form when obtaining data. ANS: 2 Feedback 1.Hospital policies may be unit and discipline specific. 2.Multidisciplinary relationships include sharing information and having respect for differences in opinion. 3. Questions should be asked in order to strive for the best care possible for a patient. 4. Forms are important, but do not always reflect needs of the entire staff. 19. Which finding most likely demonstrates lack of full disclosure? 1. 1. Health questionnaire completed in the waiting room 2. 2. Inability to explain how long symptoms have occurred 3. 3. Poor eye contact during exam 4. 4. Providing family history ANS: 2Feedback 1. Others may be able to see the paperwork being filled out in a waiting room. 2. Potential embarrassment and disgrace to have a disease may prevent the patient or caregiver from discussing the length of symptoms. 3. Based on culture, eye contact may not be allowed. 4. Family history does not provide full disclosure of the needs of the patient. 20. A parent with a low-income job can get more groceries with less money when: 1. 1. Purchasing processed food. 2. 2. Purchasing fresh fruits and vegetables. 3. 3. Purchasing meat products. 4. 4. Purchasing snack foods. ANS: 1 Feedback 1. Processed foods are less expensive and have lower nutritional value than fresh foods. 2. Fresh fruits and vegetables tend to be higher priced in certain parts of the country because of the cost of shipping and the season. 3. Meat is expensive because of the cost of processing and shipping. 4.Snack foods come in small packages and do not provide nutritional content. Snack foods are more expensive for the quantity. 21. The nurse tells the caregivers of a 5-year-old patient that the patient will be discharged at lunch time. At 12:00 noon, the family is not present, but does come in at 2:00 p.m. The caregivers are wondering why the nurse thinks that they are late. This could be attributed to: 1. 1. Lack of discharge paper processing. 2. 2. Cultural differences in lunch time. 3. 3. The caregivers believing that the child is being watched adequately. 4. 4. The nurse being busy and losing track of time. ANS: 2Feedback 1. The discharge paper processing cannot be completed without the caregivers being present. 2. Appointments should be made by clock time, not daily event times. 3.The caregivers may have a difference of opinion on time. 4.The later discharge occurred because the caregiver did not arrive at the set time. 22. The female caregiver of a patient wears a scarf that covers her head and face when males enter the room. The nurse noted that male nurses were entering the room without notice to the caregiver. The nurses best action would be to: 1. 1. No intervention is needed by the nurse. 2. 2. Place a sign on the door stating that all males must first knock and ask permission prior to entering the room. 3. 3. Only allow female caregivers. 4. 4. Only allow male caregivers. ANS: 2 Feedback 1.A plan should be made to help the female care provider feel at ease. 2.The family is considered the patient in pediatrics. Nurses should advocate and provide interventions that will maintain the cultural beliefs of the family unit. 3.Solely female caregivers may not be arranged because of staffing. 4.Solely male caregivers may not be arranged because of staffing. 23. Due to genetics, African American patients are at higher risk for: 1. 1. Liver cancer. 2. 2. Injury. 3. 3. Infectious diseases. 4. 4. Diabetes. ANS: 4Feedback 1. Liver cancer is seen more in Caucasian males. 2. Injury is the highest risk factor for all ages of children, no matter the race. 3. Infectious diseases do not have a higher presence in one race over another. 4. African Americans are at a higher risk for diabetes due to genetics. 24. European Americans may wear a horn charm to ward off evil spirits. They believe that diseases may be caused from a curse called: 1. 1. The evil spirit of the ancestors. 2. 2. The disease. 3. 3. The evil spell. 4. 4. The maloic. ANS: 4 Feedback 1. The curse of the evil spirits may be a reason to wear the horn. 2. The disease is not seen as an evil spirit. 3. The evil spell can be the outcome of the disease process. 4. The maloic is the curse that is thought to cause disease. 25. Asian Americans may use this to cure diseases. 1. 1. Balance of hot and cold fluids 2. 2. Increased vegetable intake 3. 3. Increase in exercise to sweat out impurities 4. 4. Well-balanced diet ANS: 1 Feedback1.Asians believe in the balance of hot and cold in the body. 2.Vegetables are common in the Asian American diet. 3.Exercise is not seen as a way to rid impurities of the body in order to help with an illness. 4.A well-balanced diet is important, but is not noted to be the cure of for diseases. 26. Spirituality can be defined as: 1. 1. Defining God. 2. 2. Feeling a greater being has control over world events. 3. 3. The concept of where and how the human race began. 4. 4. All of the above. ANS: 4 Feedback 1.God can come in different forms for all patients and caregivers. 2.A greater being gives a sense of control. 3.Ideas of how the human race began helps with coping for patients. 4.Spirituality is defining God, feeling a greater being has control over world events, and the concept of where and how the human race began. 27. This religious affiliation may not accept blood products, so frequent blood draws and procedures that may involve blood loss should be limited. 1. 1. Atheism 2. 2. Buddhism 3. 3. Jehovahs Witness 4. 4. Judaism ANS: 3 Feedback 1. Atheism does not have a belief system that affects any medical procedure.2. Buddhism seeks a balance and will accept blood products. 3.Jehovahs Witnesses may not accept blood transfusions. 4.Judaism allows for blood procedures. 28. These two religious affiliations do not eat pork products. 1. 1. Muslim and Mormonism 2. 2. New Age and Atheism 3. 3. Judaism and Muslim 4. 4. Judaism and Buddhism ANS: 3 Chapter 5. End-of-Life Care Multiple Choice 1. The pediatric nurse is having a conversation with parents who have children that have recently passed away. The nurse knows the parents understand the difference between bereavement and grief when the participants state: 1. I am trying to prepare for my daughters death, but I just am not ready to do so. 2. Bereavement has caused me to experience sorrow for the loss of my daughter. 3. I cant believe my daughter is gone. 4. If I make a deal that God takes me, then my daughter could come back to my family. ANS: 2 Feedback 1. The parents are stating anticipatory grief. 2. The parents are stating bereavement. 3. The parents are in the denial phase of grieving.4. The parents are bargaining. 2. The medical chart states that the parents are requesting withdrawal of care for a child with terminal leukemia. The nurse understands this request to mean: 1. To keep support measures which sustain life for the child. 2. To keep providing comfort care for the child. 3. To stop life-saving measures and allow the child to die naturally. 4. To stop providing comfort measures for the child. ANS: 3 Feedback 1. Support measures are not wanted by the parents. 2. Comfort care is important, but this addresses the life-sustaining measures. 3. Withdrawal of care relates to stopping heroic measures to sustain life. 4.Comfort is essential in the last days of life for the family and the patient. 3. Ashley is a 5-year-old girl who is severely mentally handicapped and has been bedridden for the last 3 years after a near-drowning accident. Ashley has developed pneumonia and sustaining her life would require ventilator support. The staff nurse is to obtain information about legal guardianship because her parents have abandoned her at the hospital. The nurse knows that: 1. Legal guardianship is needed for a person to have medical information released to him/her. 2. The legal guardian must be present to care for the child. 3. Legal guardianship can only be obtained by her parents. 4. The legal guardian must take physical responsibility for the child.ANS: 1 Feedback 1. The medical information and consent needs to be given by someone with the best interests of the child in mind who can legally make decisions. Only information can be released to this person. 2. The legal guardian does not need to be physically present, but must be reachable to discuss the plan of care. 3. Legal guardians can be anyone with the best interests of the child in mind. 4. The legal guardian may be the state, and foster parents would have the physical responsibility of caring for the child. 4. Identify a developmentally-appropriate activity that can be used to speak to a 6 year old about the terminal illness of his sibling. 1. Playing checkers and speaking about the illness. 2. Playing with action figures and discussing how death occurs. 3. Playing with crayons and drawing pictures of how a child views his sibling at this time. 4. All of the above are correct. ANS: 4 Feedback 1. Having a diversional activity allows the child to express themselves without having to look directly at the adult. 2. Action figures can help act out how death occurs. 3.Expression through art is a technique that children are able to comprehend and is not threatening to them. 4. Diversion, acting, and art can help children express and discuss the death process. 5. Palliative care should be considered for a terminally-ill child:1. Within 1 year of death. 2. Within 2 months of death. 3. When a terminal illness is present. 4. At no time. It is not appropriate for children. ANS: 3 Feedback 1. Planning can occur, but should be started when a terminal diagnosis is present to provide the plan of care for the child. 2. Planning can occur, but
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The nur should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client&039;s skin. a nur is reinforcing teaching about hopsice care measures with the family of a client who is dying. Which of the following statements by a member of the fmaily indicates an understading of the teaching 1"We will make sure she eats three meals a day." 2."We will decrease her pain medication if she gets too drowsy." 3."We will keep her room cool to help her breathe better." 4."We will make sure to provide oral care twice a day." 3."We will keep her room cool to help her breathe better." -Clients who are dying will have thick secretions and decreased muscle tone, which can make breathing more difficult. Keeping the air in the room cool will ease the work of breathing. A nur is reinforcing teaching about health promotion with a group of young adults clients. Which of the following information should the nur include? 1. Young adults should receive a dental assessment every 6 months 2. Young adult males should have a testicular examination every 5 yrs 3. Young adult females should have a routine physical 4. Young adults should receive a tuberculosis skin test every 3 yrs 1. Young adults should receive a dental assessment every 6 months
The nurse is assessing a client who has a bowel obstruction. Which observations should the nurse expect to find? (Select all that apply) A. Peristaltic waves observed B. Abdominal distention C. High-pitch bowel sounds D. Dullness on percussion E. Abdomen soft on palpations - answersB, C, D A male client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for his oral temperature of 103 degrees F and an infusion of normal saline is initiated at 250 mL/hour. Which assessment finding should the nurse report to the healthcare provider immediately. A. Severe headache with photosensitivity B.Petechial hemorrhage under client&039;s eyes C. Right lower abdomen rebound tenderness D. Dark green color emesis - answersB A client who fractured the right femur from a fall at home is placed in a skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? A. Insert an indwelling catheter preoperatively B.Release the traction so the client can use a bedpan C. Log roll the client and place adult disposable briefs beneath the client D. Maintain traction while the client uses a female urinal - answers
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