Test Bank - Advanced Pediatric Assessment, 3rd Edition ( Ellen M .Chiocca, ) All Chapters 2024

Test Bank - Advanced Pediatric Assessment, 3rd Edition ( Ellen M .Chiocca, ) All Chapters 2024 Test Bank - Advanced Pediatric Assessment Advanced Pediatric Assessment Third Edition Test Bank Chapter 1. Child Health Assessment: An Overview 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: dm 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) program ANS: 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 well-child 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: dm 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: dm 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 nurses b. 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: dm 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: dm 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: dm 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: dm 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: dm 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: dm 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: dm 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: dm 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. Assessment of Child Development and Behavior MULTIPLE CHOICE 1. The nurse is performing an abdominal assessment on a child. When percussing over the stomach, the nurse should hear which sound? a. Tympany b. Resonance c. Flatness d. Dullness ANS: A Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle. Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver. DIF: Cognitive Level: Application REF: dm 170 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 2. A nurse is preparing to begin an assessment on a newly admitted child. The nurse should be aware that the single most important component of a pediatric physical examination is: a. assessment of heart and lungs. b. measurement of height and weight. . c. documentation of parental concerns. d. obtaining an accurate history. ANS: D An accurate history is most helpful in identifying problems and potential problems. Heart and lung assessment and documentation of parental concerns are not as important as an accurate history. A single measurement of height and weight is not as significant as determining growth over time. The childs growth pattern can be elicited from the history. DIF: Cognitive Level: Comprehension REF: dm 171 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 3. In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea? a. Review of systems b. Chief complaint c. Lifestyle and life patterns d. Health history ANS: B The chief complaint is documented using the childs or parents words for the reason the child was brought to the healthcare center. The review of systems includes past health functions of body systems. Lifestyle and life patterns include the childs interaction with the social, psychological, physical, and cultural environment. Health history includes birth history, growth and development, common childhood illnesses, immunizations, hospitalizations, injuries, and allergies. DIF: Cognitive Level: Comprehension REF: dm 171 OBJ: Nursing Process Step: Implementation . MSC: Health Promotion and Maintenance 4. A nurse is reviewing pediatric physical assessment techniques. Which statement about performing a pediatric physical assessment is correct? a. Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise. b. The physical examination should be done with parents in the examining room for children of any age. c. Measurement of head circumference is done until the child is 5 years old. d. The physical examination is done only when the child is cooperative. ANS: A Physical assessment usually proceeds from head to toe; however, developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data. Having parents in the examining room with adolescents is not appropriate. Head circumference is routinely measured until 36 months of age. Children will not always be cooperative during the physical examination. The examiner will need to incorporate communication and play techniques to facilitate cooperation. DIF: Cognitive Level: Comprehension REF: dm 168 OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance 5. A nurse is conducting an assessment on a child during a well-child visit. Which of the following includes the components of a complete pediatric history? a. Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns b. Vital signs, chief complaint, and a list of previous problems c. Chief complaint, including body location, quality, quantity, time frame, and alleviating and aggravating factors d. Pertinent developmental and family information ANS: A . Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns are included in a complete pediatric history. Vital signs, chief complaint, and list of previous problems do not constitute a complete history. A problemoriented history includes specific information about the chief complaint. Pertinent developmental and family information are part of the complete history. DIF: Cognitive Level: Comprehension REF: dm 171 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 6. At what age can the nurse expect a childs head and chest circumference to be almost equal? a. Birth b. 6 months c. 1 year d. 3 years ANS: C Head and chest measurements are almost equal at 1 year of age. Head circumference is larger than chest circumference until approximately 1 year of age. By 3 years of age, the chest circumference exceeds the head circumference. DIF: Cognitive Level: Knowledge REF: dm 174 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 7. A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure on children. The nurse knows the UAPs have understood the teaching if they state that to obtain an accurate measurement of a childs blood pressure, the cuff should cover which portion of the childs upper arm? a. Two-thirds b. Three-fourths c. One-half . d. One-third ANS: A The blood pressure cuff should cover two-thirds of the childs upper arm to get an accurate reading. A cuff that covers more than two-thirds of the childs upper arm will result in a false low reading. A cuff that covers less than two-thirds of the childs upper arm will result in a false high reading. DIF: Cognitive Level: Application REF: dm 173 OBJ: Nursing Process Step: Evaluation MSC: Safe and Effective Care Environment 8. Which chart should the nurse use to assess the visual acuity of an 8-year-old child? a. Lea chart b. Snellen chart c. HOTV chart d. Tumbling E chart ANS: B The Snellen chart is used to assess the vision of children older than 6 years of age. The Lea chart tests vision using four different symbols designed for use with preschool children. The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years. The Tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years. DIF: Cognitive Level: Comprehension REF: dm 180 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 9. Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child? . a. Ask the parent to quiet the child so the nurse can listen. b. Auscultate breath sounds and chart that the child was crying. c. Encourage the child to play with the stethoscope to distract and to calm down the child before auscultating. d. Document that data are not available because of noncompliance. ANS: C Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made. Asking a parent to quiet the child may or may not work. Auscultating while the child is crying typically results in less than optimal data. Documenting that the child is not compliant is not appropriate. An assessment needs to be completed. DIF: Cognitive Level: Application REF: dm 186 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 10. Which is the most appropriate site for the nurse to use to measure a pulse rate on a 1-year-old child? a. Apical b. Radial c. Carotid d. Femoral ANS: A Apical pulse rates are taken in children younger than 2 years. Radial pulse rates may be taken in children older than 2 years. It is difficult to palpate the carotid pulse in an infant. The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infants pulse rate. DIF: Cognitive Level: Comprehension REF: dm 172 . OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 11. What is the most appropriate action for the nurse to take when a crying toddler has a blood pressure measurement of 120/70 mm Hg? a. Notify the physician of the measurement. b. Document the blood pressure reading and check it again in 4 hours. c. Quiet the child and retake the blood pressure. d. Ask the parent if the child has a history of hypertension. ANS: C Blood pressure is elevated when a child is upset and crying. Quieting the child before retaking the blood pressure is appropriate. Notifying the physician is not necessary until accurate data are obtained. Documenting the blood pressure and waiting 4 hours before taking another measurement is inappropriate because this reading is not within the normal range. Asking the parent about a history of hypertension is irrelevant when a child is upset and crying as blood pressure is elevated. DIF: Cognitive Level: Application REF: dm 173 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 12. What term should be used in the nurses documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration? a. Pleural friction rub b. Bronchovesicular sounds c. Crackles d. Wheeze ANS: C . Crackles are short, popping, discontinuous sounds heard on inspiration. A pleural friction rub has a grating, coarse, low-pitched sound. Bronchovesicular sounds are auscultated over mainstem bronchi. They are clear, without any adventitious sounds. Wheezes are musical, high-pitched, predominant sounds heard on expiration. DIF: Cognitive Level: Comprehension REF: dm 188 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 13. Which strategy should be the best approach when initiating the physical examination of a 9- month-old infant? a. Undress the infant and do a head-to-toe examination. b. Have the parent hold the child on his or her lap. c. Put the infant on the examination table and begin assessments at the head. d. Ask the parent to leave because the infant will be upset. ANS: B Infants 6 months and older feel stranger anxiety. It is easier to do most of the examination on the parents lap to decrease anxiety. The head-to-toe approach needs to be modified for the infant. Uncomfortable procedures, such as the otoscopic examination, should be left until last. The infant may feel less fearful if placed in the parents lap or with the parent within visual range if placed on the examining table. There is no reason to ask a parent to leave when an infant is being examined. Having the parent with the infant will make the experience less upsetting for the infant. DIF: Cognitive Level: Comprehension REF: dm 169 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 14. Which strategy is not always appropriate for a pediatric physical examination? . a. Take the history in a quiet, private place. b. Examine the child from head to toe. c. Exhibit sensitivity to cultural needs and differences. d. Perform frightening procedures last. ANS: B The classic approach to a physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner must tailor the physical assessment to the childs age and developmental level. The nurse should collect the childs health history in a quiet, private area and painful or frightening procedures should be left to the end of the examination. The nurse should always be sensitive to cultural needs and differences among children. DIF: Cognitive Level: Comprehension REF: dm 168 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 15. Which assessment should the nurse perform last when examining a 5-year-old child? a. Heart b. Lungs c. Abdomen d. Throat ANS: D Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination. The nurse may proceed from head to toe with preschool age children. Assessment of the abdomen and lungs is not considered to be frightening. DIF: Cognitive Level: Application REF: dm 169 . OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 16. When would be the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old female? a. It is not necessary to inspect the genital area. b. Examine the genital area first. c. After the abdominal assessment. d. Do the genital inspection last. ANS: C It is best to incorporate the genital assessment into the middle of the examination. This allows ample time for questions and discussion. If possible, proceed from the abdominal area to the genital area. A visual inspection of all areas of the body is included in a physical examination. Examination of the genital area can be embarrassing. It would not be appropriate to begin the examination of this area. Assessing the genital area earlier in the examination allows more time for the adolescent to ask questions and engage in discussioTest Bank - Advanced Pediatric Assessment, 3rd Edition ( Ellen M .Chiocca, ) All Chapters 2024 Test Bank - Advanced Pediatric Assessment Advanced Pediatric Assessment Third Edition Test Bank Chapter 1. Child Health Assessment: An Overview 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: dm 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) program ANS: 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 well-child 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: dm 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: dm 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 nurses b. 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: dm 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: dm 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: dm 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: dm 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: dm 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: dm 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: dm 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: dm 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. Assessment of Child Development and Behavior MULTIPLE CHOICE 1. The nurse is performing an abdominal assessment on a child. When percussing over the stomach, the nurse should hear which sound? a. Tympany b. Resonance c. Flatness d. Dullness ANS: A Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle. Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver. DIF: Cognitive Level: Application REF: dm 170 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 2. A nurse is preparing to begin an assessment on a newly admitted child. The nurse should be aware that the single most important component of a pediatric physical examination is: a. assessment of heart and lungs. b. measurement of height and weight. . c. documentation of parental concerns. d. obtaining an accurate history. ANS: D An accurate history is most helpful in identifying problems and potential problems. Heart and lung assessment and documentation of parental concerns are not as important as an accurate history. A single measurement of height and weight is not as significant as determining growth over time. The childs growth pattern can be elicited from the history. DIF: Cognitive Level: Comprehension REF: dm 171 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 3. In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea? a. Review of systems b. Chief complaint c. Lifestyle and life patterns d. Health history ANS: B The chief complaint is documented using the childs or parents words for the reason the child was brought to the healthcare center. The review of systems includes past health functions of body systems. Lifestyle and life patterns include the childs interaction with the social, psychological, physical, and cultural environment. Health history includes birth history, growth and development, common childhood illnesses, immunizations, hospitalizations, injuries, and allergies. DIF: Cognitive Level: Comprehension REF: dm 171 OBJ: Nursing Process Step: Implementation . MSC: Health Promotion and Maintenance 4. A nurse is reviewing pediatric physical assessment techniques. Which statement about performing a pediatric physical assessment is correct? a. Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise. b. The physical examination should be done with parents in the examining room for children of any age. c. Measurement of head circumference is done until the child is 5 years old. d. The physical examination is done only when the child is cooperative. ANS: A Physical assessment usually proceeds from head to toe; however, developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data. Having parents in the examining room with adolescents is not appropriate. Head circumference is routinely measured until 36 months of age. Children will not always be cooperative during the physical examination. The examiner will need to incorporate communication and play techniques to facilitate cooperation. DIF: Cognitive Level: Comprehension REF: dm 168 OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance 5. A nurse is conducting an assessment on a child during a well-child visit. Which of the following includes the components of a complete pediatric history? a. Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns b. Vital signs, chief complaint, and a list of previous problems c. Chief complaint, including body location, quality, quantity, time frame, and alleviating and aggravating factors d. Pertinent developmental and family information ANS: A . Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns are included in a complete pediatric history. Vital signs, chief complaint, and list of previous problems do not constitute a complete history. A problemoriented history includes specific information about the chief complaint. Pertinent developmental and family information are part of the complete history. DIF: Cognitive Level: Comprehension REF: dm 171 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 6. At what age can the nurse expect a childs head and chest circumference to be almost equal? a. Birth b. 6 months c. 1 year d. 3 years ANS: C Head and chest measurements are almost equal at 1 year of age. Head circumference is larger than chest circumference until approximately 1 year of age. By 3 years of age, the chest circumference exceeds the head circumference. DIF: Cognitive Level: Knowledge REF: dm 174 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 7. A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure on children. The nurse knows the UAPs have understood the teaching if they state that to obtain an accurate measurement of a childs blood pressure, the cuff should cover which portion of the childs upper arm? a. Two-thirds b. Three-fourths c. One-half . d. One-third ANS: A The blood pressure cuff should cover two-thirds of the childs upper arm to get an accurate reading. A cuff that covers more than two-thirds of the childs upper arm will result in a false low reading. A cuff that covers less than two-thirds of the childs upper arm will result in a false high reading. DIF: Cognitive Level: Application REF: dm 173 OBJ: Nursing Process Step: Evaluation MSC: Safe and Effective Care Environment 8. Which chart should the nurse use to assess the visual acuity of an 8-year-old child? a. Lea chart b. Snellen chart c. HOTV chart d. Tumbling E chart ANS: B The Snellen chart is used to assess the vision of children older than 6 years of age. The Lea chart tests vision using four different symbols designed for use with preschool children. The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years. The Tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years. DIF: Cognitive Level: Comprehension REF: dm 180 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 9. Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child? . a. Ask the parent to quiet the child so the nurse can listen. b. Auscultate breath sounds and chart that the child was crying. c. Encourage the child to play with the stethoscope to distract and to calm down the child before auscultating. d. Document that data are not available because of noncompliance. ANS: C Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made. Asking a parent to quiet the child may or may not work. Auscultating while the child is crying typically results in less than optimal data. Documenting that the child is not compliant is not appropriate. An assessment needs to be completed. DIF: Cognitive Level: Application REF: dm 186 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 10. Which is the most appropriate site for the nurse to use to measure a pulse rate on a 1-year-old child? a. Apical b. Radial c. Carotid d. Femoral ANS: A Apical pulse rates are taken in children younger than 2 years. Radial pulse rates may be taken in children older than 2 years. It is difficult to palpate the carotid pulse in an infant. The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infants pulse rate. DIF: Cognitive Level: Comprehension REF: dm 172 . OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 11. What is the most appropriate action for the nurse to take when a crying toddler has a blood pressure measurement of 120/70 mm Hg? a. Notify the physician of the measurement. b. Document the blood pressure reading and check it again in 4 hours. c. Quiet the child and retake the blood pressure. d. Ask the parent if the child has a history of hypertension. ANS: C Blood pressure is elevated when a child is upset and crying. Quieting the child before retaking the blood pressure is appropriate. Notifying the physician is not necessary until accurate data are obtained. Documenting the blood pressure and waiting 4 hours before taking another measurement is inappropriate because this reading is not within the normal range. Asking the parent about a history of hypertension is irrelevant when a child is upset and crying as blood pressure is elevated. DIF: Cognitive Level: Application REF: dm 173 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 12. What term should be used in the nurses documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration? a. Pleural friction rub b. Bronchovesicular sounds c. Crackles d. Wheeze ANS: C . Crackles are short, popping, discontinuous sounds heard on inspiration. A pleural friction rub has a grating, coarse, low-pitched sound. Bronchovesicular sounds are auscultated over mainstem bronchi. They are clear, without any adventitious sounds. Wheezes are musical, high-pitched, predominant sounds heard on expiration. DIF: Cognitive Level: Comprehension REF: dm 188 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance 13. Which strategy should be the best approach when initiating the physical examination of a 9- month-old infant? a. Undress the infant and do a head-to-toe examination. b. Have the parent hold the child on his or her lap. c. Put the infant on the examination table and begin assessments at the head. d. Ask the parent to leave because the infant will be upset. ANS: B Infants 6 months and older feel stranger anxiety. It is easier to do most of the examination on the parents lap to decrease anxiety. The head-to-toe approach needs to be modified for the infant. Uncomfortable procedures, such as the otoscopic examination, should be left until last. The infant may feel less fearful if placed in the parents lap or with the parent within visual range if placed on the examining table. There is no reason to ask a parent to leave when an infant is being examined. Having the parent with the infant will make the experience less upsetting for the infant. DIF: Cognitive Level: Comprehension REF: dm 169 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 14. Which strategy is not always appropriate for a pediatric physical examination? . a. Take the history in a quiet, private place. b. Examine the child from head to toe. c. Exhibit sensitivity to cultural needs and differences. d. Perform frightening procedures last. ANS: B The classic approach to a physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner must tailor the physical assessment to the childs age and developmental level. The nurse should collect the childs health history in a quiet, private area and painful or frightening procedures should be left to the end of the examination. The nurse should always be sensitive to cultural needs and differences among children. DIF: Cognitive Level: Comprehension REF: dm 168 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 15. Which assessment should the nurse perform last when examining a 5-year-old child? a. Heart b. Lungs c. Abdomen d. Throat ANS: D Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination. The nurse may proceed from head to toe with preschool age children. Assessment of the abdomen and lungs is not considered to be frightening. DIF: Cognitive Level: Application REF: dm 169 . OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 16. When would be the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old female? a. It is not necessary to inspect the genital area. b. Examine the genital area first. c. After the abdominal assessment. d. Do the genital inspection last. ANS: C It is best to incorporate the genital assessment into the middle of the examination. This allows ample time for questions and discussion. If possible, proceed from the abdominal area to the genital area. A visual inspection of all areas of the body is included in a physical examination. Examination of the genital area can be embarrassing. It would not be appropriate to begin the examination of this area. Assessing the genital area earlier in the examination allows more time for the adolescent to ask questions and engage in discussion. DIF: Cognitive Level: Application REF: dm 169 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 17. Which measurement is not indicated for a 4-year-old well-child examination? a. Blood pressure b. Weight c. Height n. DIF: Cognitive Level: Application REF: dm 169 OBJ: Nursing Process Step: Implementation MSC: Health Promotion and Maintenance 17. Which measurement is not indicated for a 4-year-old well-child examination? a. Blood pressure b. Weight c. Height