2012 Nursing Care of Children Principles and Practice 4e Test Bank

2012 Nursing Care of Children Principles and Practice, 4e Test Bank
2012 Nursing Care of Children Principles and

Practice, 4e Test Bank
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Chapter 10: Emergency Care of Children
Test Bank
MULTIPLE CHOICE
1. Which nursing action would facilitate care being provided to a child in an emergency situation?
a. Encourage the family to remain in the waiting room.
b. Assist parents in distracting the child during a procedure.
c. Always reassure the child and family.
d. Give explanations using professional terminology.
ANS: B
Include parents as partners in the child’s treatments. Parents may need direct guidance in concrete
terms to help distract the child. Allowing the parents to remain with the child may help calm the child.
Telling the truth is the most important thing. False reassurance does not facilitate a trusting
relationship. Professional terminology may not be understood. Speak to the child and family in
language that they will understand.
DIF: Cognitive Level: Comprehension REF: p. 203|p. 205

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity
2. The father of a child in the emergency department is yelling at the physician and nurses. Which action
would be contraindicated in this situation?
a. Provide a nondefensive response.
b. Encourage the father to talk about his feelings.
c. Speak in simple, short sentences.
d. Tell the father he must wait in the waiting room.
ANS: D
Because a parent who is upset may be aggravated by observers, he should be directed to a quiet area.
When dealing with parents who are upset, it is important not to be defensive or attempt to justify
anyone’s actions. Encouraging the father to talk about his feelings may assist him to acknowledge his
emotions and may defuse his angry reaction. People who are upset need to be spoken to with simple
words (no longer than five letters) and short sentences (no more than five words).
DIF: Cognitive Level: Application REF: p. 204

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity
3. Which would be an appropriate nursing intervention for a 6-month-old infant in the emergency
department?
a. Distract the infant with noise or bright lights.
b. Avoid warming the infant.
c. Remove any pacifiers from the baby.
d. Encourage the parent to hold the infant.
ANS: D
Parents should be encouraged to hold the infant as much as possible while in the emergency
department. Having the parent hold the infant may help to calm the child. Distraction with noise or
bright lights would be most appropriate for a preschool-age child. In an emergency healthcare facility,
it is important to keep infants warm. Infants use pacifiers to comfort themselves; therefore, the pacifier
should not be taken away.
DIF: Cognitive Level: Application REF: pp. 204-205

4. Which action should the nurse working in the emergency department initiate to decrease fear in a
2-year-old child?
a. Keep the child physically restrained during nursing care.
b. Allow the child to hold a favorite toy or blanket.
c. Direct the parents to remain outside the treatment room.
d. Let the child decide whether to sit up or lie down for procedures.
ANS: B
Allowing a child to hold a favorite toy or blanket is comforting. It may be necessary to restrain the
toddler for some nursing care or procedures. Because toddlers need autonomy and do not respond well
to restrictions, the nurse should remove any restriction or restraint as soon as safety permits. Parents
should remain with the child as much as possible to calm and reassure the child. The toddler should
not be given the overwhelming choice of deciding which position she prefers.

5. Which nursing action would be most appropriate to assist a preschool-age child in coping with the
emergency department experience?
a. Explain the procedures and give the child some time to prepare.
b. Remind the child that she is a big girl.
c. Avoid the use of bandages.
d. Use positive terms and avoid terms such as “shot” and “cut.”
ANS: D
Using positive terms and avoiding words that have frightening connotations assist the child in coping.
Preschool-age children should be told about procedures immediately before they are done. Time to
prepare only allows time for fantasies and increased anxiety. Children should not be shamed into
cooperation. Bandages are important to preschool-aged children. Children in this age group believe
that their insides can leak out and that bandages stop this from happening.

6. Which action should the nurse incorporate into a care plan for a 14-year-old child in the emergency
department?
a. Limit the number of choices to be made by the adolescent.
b. Insist that parents remain with the adolescent.
c. Provide clear explanations and encourage questions.
d. Give rewards for cooperation with procedures.
ANS: C
Adolescents are capable of abstract thinking and can understand explanations. They should be offered
the opportunity to ask questions and make decisions. Adolescents should have the choice of whether
parents remain with them. They are very modest, and this modesty should be respected. Giving
rewards such as stickers for cooperation with treatments or procedures is more appropriate for the
younger child.

OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity
7. The emergency department nurse notices that the mother of a young child is making a lot of phone
calls and getting advice from her friends about what she should do. This behavior is an indication of
which of the following?
a. Stress
b. Healthy coping skills
c. Attention-getting behaviors
d. Low self-esteem
ANS: A
Hyperactive behavior such as making a lot of phone calls and enlisting everyone’s opinions is a sign of
stress. This is not a healthy coping skill and may be an attention-getting behavior or indicative of the
mother having low self-esteem, but is more likely an indicator of stress.
DIF: Cognitive Level: Analysis REF: p. 206

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity
8. A preschool child in the emergency department has a respiratory rate of 10 breaths per minute. How
should the nurse interpret this finding?
a. The child is relaxed.
b. Respiratory failure is likely.
c. This child is in respiratory distress.
d. The child’s condition is improving.
ANS: B
Very slow breathing in an ill child is an ominous sign, indicating respiratory failure. Although the
respiratory rate slows when an individual is relaxed, a rate of 10 breaths per minute in an ill preschool
child is not a normal finding and is cause for concern. A rapid respiratory rate indicates respiratory
distress. Other signs of respiratory distress may include retractions, grunting, and nasal flaring.

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity
9. The nurse observes abdominal breathing in a 2-year-old child. What would this finding indicate?
a. Imminent respiratory failure
b. Hypoxia
c. Normal respiration
d. Airway obstruction
ANS: C
Young children normally exhibit abdominal breathing. When measuring respiratory rate, the nurse
should observe the rise and fall of the abdomen. A very slow respiration rate is an indicator of
respiratory failure. Nasal flaring with inspiration and grunting on expiration would occur when
hypoxia is present. The child with an airway obstruction will use accessory muscles to breathe.

10. What should be the emergency department nurse’s next action when a 6-year-old child has a systolic
blood pressure of 58 mm Hg?
a. Alert the physician about the systolic blood pressure.
b. Comfort the child and assess the respiratory rate.
c. Assess the child’s responsiveness to the environment.
d. Alert the physician that the child may need intravenous fluids.
ANS: A
Hypotension is a late sign of shock in children. The lower limit for systolic blood pressure for a child
older than 1 year is 70 mm Hg plus two times the child’s age in years. A systolic blood pressure of 58
mm Hg calls for immediate action. The nurse should be direct in relaying the child’s condition to the
physician. Comforting the child and assessing the respiratory rate do not address the problem of shock,
which requires immediate intervention. Assessing the child’s responsiveness is included in a
neurological assessment. It does not address the systolic blood pressure of 58 mm Hg. Although this
child most likely requires intravenous fluids, the physician must be apprised of the systolic blood
pressure so that appropriate intervention can be initiated.
DIF: Cognitive Level: Analysis REF: p. 213|p. 215

11. A nurse is checking the emergency medications. The nurse should check for which drug of choice for
management of cardiac arrest?
a. Atropine sulfate
b. Epinephrine
c. Sodium bicarbonate
d. Dopamine
ANS: B
Epinephrine is the drug of choice for the management of cardiac arrest. Atropine sulfate is used to treat
symptomatic bradycardia. Sodium bicarbonate is given to treat severe acidosis associated with cardiac
arrest. Dopamine is indicated for hypotension or poor peripheral circulation in a child.

12. A nurse is performing triage in the emergency department. Which is part of a primary assessment in an
emergency setting?
a. Determine the level of consciousness.
b. Obtain a health history.
c. Obtain a full set of vital signs.
d. Evaluate for pain.
ANS: A
A primary assessment consists of assessing airway, breathing, circulation, the child’s level of
consciousness, and exposure (ABCDEs). Obtaining the child’s health history is a component of a
secondary assessment. Vital signs are included in a secondary assessment, after the ABCDEs are
assessed. Assessing for pain is a component of a secondary assessment.
DIF: Cognitive Level: Comprehension REF: p. 206

13. What is the goal of the initial intervention for a child in cardiopulmonary arrest?
a. Establishing a patent airway
b. Determining a pulse rate
c. Removing clothing
d. Reassuring the parents
ANS: A
The first intervention for a child in cardiopulmonary arrest, as for an adult, is to establish a patent
airway. Assessment of pulse follows the establishment of a patent airway. Clothing may be removed
from the upper body for chest compressions after a patent airway is established.

14. What is the nurse’s immediate action when a child comes to the emergency department with sweating,
chills, and fang bite marks on the thigh?
a. Secure antivenin.
b. Apply a tourniquet to the leg.
c. Ambulate the child.
d. Reassure the child and parent.
ANS: A
Antivenin is essential to the child’s survival because the child is showing signs of envenomation. The
use of a tourniquet is no longer recommended. When a bite or envenomation is located on an
extremity, the extremity should be immobilized. Envenomation is a potentially life-threatening
condition. False reassurance is not helpful for building a trusting relationship.

15. A mother calls the emergency department and reports that her 9-year-old child has just fallen on his
face and one of his front teeth fell out. How should the nurse instruct the mother?
a. Put the tooth back in the child’s mouth and call the dentist right away.
b. Place the tooth in milk or water and go directly to the emergency department.
c. Gently place the tooth in a plastic zippered bag until she makes a dental appointment.
d. Clean the tooth and call the dentist for an immediate appointment.
ANS: B
The parent should be told to keep the tooth moist by placing it in saline solution, water, milk, or a
commercial tooth-preserving solution and get the child evaluated as soon as possible. The parent may
replace the tooth incorrectly so it is best not to advise the parent to put the tooth back in the child’s
mouth. Cleaning or scrubbing the tooth could damage it. It is essential for the child to have an
immediate dental evaluation.

16. A nurse is preparing to admit a child who suffered a submersion injury. The nurse recognizes that
damage to organ systems in submersion injuries is the result of which?
a. Respiratory acidosis
b. Hypothermia
c. Hypoglycemia
d. Hypoxia
ANS: D
Hypoxia is responsible for the injury to organ systems during submersion injuries. Respiratory acidosis
occurs as a result of hypoxia. Severe hypothermia offers protection to the brain. Hypoglycemia is not
responsible for organ damage in submersion injuries.

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity
17. What would be the best approach for preventing absorption in an 18-month-old child who has
swallowed over-the-counter antihistamine tablets 30 minutes ago?
a. Diluting the toxic substance with water or milk
b. Administering naloxone
c. Administering activated charcoal with a oral syringe
d. Administering ipecac syrup
ANS: C
Activated charcoal has become the recommended treatment for acute poisonings in the pediatric
population and is most effective when administered within 60 minutes of ingestion. Dilution is used
for acid or alkali ingestions. Naloxone (Narcan) is the antidote for an opioid overdose. It is not
indicated for use in ingestion of antihistamine tablets. Ipecac is no longer recommended as the first
line of treatment for treating accidental ingestions.
DIF: Cognitive Level: Analysis REF: p. 221|p. 223

18. A nurse is assessing a child brought to the emergency department with a submersion injury. The
assessment should focus on which system?
a. Cardiovascular
b. Respiratory
c. Neurological
d. Gastrointestinal
ANS: B
Assessment of the child with a submersion injury focuses on the respiratory system. Airway and
breathing are the priorities. Cardiovascular assessment is secondary to airway and breathing.
Preventing neurological impairment is a goal of intervention. Because the primary problem in
submersion injuries is hypoxia, the focus of assessment is the respiratory system. Gastrointestinal
assessment would be less of a priority than assessment of other body systems.

19. Which is the most critical element of pediatric emergency care?

a. Airway management
b. Prevention of neurological impairment
c. Maintaining adequate circulation
d. Supporting the child’s family
ANS: A
Airway management is the most critical element in pediatric emergency care. Prevention of
neurological impairment is certainly a concern in pediatric emergency care; however, it is not
considered the most critical element. Maintaining adequate circulation is accomplished after a patent
airway is established. The focus of emergency care is stabilizing the child’s physiological status.
Supporting the family is important, but it is not considered to be the most critical element in pediatric
emergency care.
DIF: Cognitive Level: Application REF: p. 206|p. 211

20. Which observation made by an emergency department nurse would raise the suspicion that a
3-year-old child has been maltreated?
a. The parents are extremely calm in the emergency department.
b. The injury is unusual for a child of that age.
c. The child does not remember how he got hurt.
d. The child was doing something unsafe when the injury occurred.
ANS: B
An injury that is rarely found in children or is inconsistent with the age and condition of the child
should raise suspicion of child maltreatment. The nurse should observe the parents’ reaction to the
child but must keep in mind that people behave very differently depending on culture, ethnicity,
experience, and psychological makeup. The child may not remember what happened as a result of the
injury itself, for example, sustaining a concussion. Also, a 3-year-old child may not be a reliable
historian. The fact that the child was not supervised might be an area for health teaching. The nurse
would need to gather more information to determine whether the parents have been negligent in the
care of their child.

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity
21. In which situation where ingestion has occurred would administration of milk or water be indicated?
a. The child is suspected of ingesting leaded paint chips.
b. The child ingested approximately 15 tablets of baby aspirin.
c. The child ingested an over-the-counter product containing acetaminophen.
d. The child ingested an acid or alkali.
ANS: D
Administering water or milk can dilute the toxic effects of acid or alkali ingestion. Ingestion of leaded
paint chips would not indicate treatment with administration of water or milk. Ingestion of aspirin is
not treated with the administration of water or milk. The treatment may involve gastric lavage with
activated charcoal, IV fluids with various additives to decrease absorption and treatment of electrolyte
imbalances, and vitamin K for bleeding tendencies. Ingestion of acetaminophen is not treated with the
administration of milk or water. Gastric lavage within 1 hour and administration of the antidote
N-acetylcysteine (Mucomyst) are indicated.

22. Which initial assessment made by the triage nurse would suggest that a child requires immediate
intervention?
a. The child has thick yellow rhinorrhea.
b. The child has a frequent nonproductive cough.
c. The child’s oxygen saturation is 95% by pulse oximeter.
d. The child is grunting.
ANS: D
One of the initial observations for triage is respiratory rate and effort. Grunting is a sign of hypoxemia
and represents the body’s attempt to improve oxygenation by generating positive end-expiratory
pressure. Nasal discharge would indicate that the child has a respiratory condition but does not mean
the child needs immediate attention. A productive cough is not a finding that would indicate the child
requires immediate attention. An oxygen saturation of 95% is a normal finding.

23. Which vital sign should be measured first when the client is a child?
a. Temperature
b. Heart rate
c. Respiratory rate
d. Blood pressure
ANS: C
When taking children’s vital signs, the nurse observes the respiratory rate first. Temperature should be
measured after other vital signs because it can be upsetting for children. Heart rate is not the first vital
sign measured in children. Blood pressure is taken after other vital signs because it can be upsetting for
children.
DIF: Cognitive Level: Knowledge REF: p. 209

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance
24. Which intervention is appropriate for a 2-year-old conscious child with an obstructed airway?
a. Heimlich maneuver
b. Abdominal thrusts
c. Five back blows
d. Five chest thrusts
ANS: A
To clear a foreign body from the airway, the American Heart Association recommends the Heimlich
maneuver for a conscious child older than 1 year of age. Abdominal thrusts are indicated when the
child is unconscious. Back blows are indicated for an infant with an obstructed airway. Chest thrusts
would follow back blows for the infant with an obstructed airway.

25. The nurse should recognize which as an early sign of distributive shock?
a. Hypotension
b. Skin warm and flushed
c. Oliguria
d. Cold, clammy skin
ANS: B
An early sign of distributive shock is extremities that are warm to the touch. Hypotension is a late sign
of all types of shock. Oliguria is a manifestation of hypovolemic shock. Cold, clammy skin is a late
sign of septic shock, which is a type of distributive shock.

26. A nurse is reviewing topics to teach at a parenting class. The nurse should include the information that
the leading cause of unintentional death in children younger than 19 years of age in the United States
is:
a. drowning.
b. airway obstruction.
c. pedestrian injury.
d. motor vehicle injuries.
ANS: D
The CDC has consistently found that motor vehicle injuries are the leading cause of unintentional
death in children younger than 18 years of age in the United States. Drowning is the second leading
cause of unintentional death for children under 18 years of age. Airway obstruction is the third leading
cause of unintentional death for children under 19 years of age. Pedestrian injuries are not the leading
cause of unintentional death in children. It is a significant problem, with most injuries occurring in
children between 1 and 4 years.

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which may cause an abnormally high heart rate in children? Select all that apply.
a. Hyperthermia
b. Pain
c. Hypoxia
d. Hypovolemia
ANS: A, B, C, D
Hyperthermia, pain, hypoxia, and hypovolemia may all cause an abnormally high heart rate in
children.

2. An emergency department nurse is making a general appearance assessment on a preschool child just
admitted to the emergency department. Which general assessment findings indicate the child “looks
bad?” Select all that apply.
a. Color pale
b. Capillary refill less than 2 seconds
c. Unwilling to separate from parents
d. Cold extremities
e. Lethargic
ANS: A, D, E
Signs of a child “looking bad” on a general appearance assessment include pale skin, cold extremities,
and lethargy. A capillary refill of less than 2 seconds is a “good sign” as well as a child who is
unwilling to separate from parents (separation anxiety, expected).

OTHER
1. Place in order the steps a nurse should follow when initiating cardiopulmonary resuscitation (CPR) on
an infant found unresponsive, not breathing, with no pulse. Begin with the initial step and end with the
last step. Use the following format for your answers: A, B, C, D
a. Open the airway.
b. Check for responsiveness.
c. Begin chest compressions.
d Check for a brachial pulse.
e. Give two breaths.
ANS:
B, D, C, A, E
The steps in CPR are now to begin chest compressions first before opening the airway and giving
breaths. The first step should be checking for responsiveness and a brachial pulse, and then chest
compressions are initiated. After chest compressions the airway is opened and breaths are given. The
chest compression and breathing cycle is continued until help arrives or if alone 911 is called after 2
minutes of giving compressions and breaths.
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DIF: Cognitive Level: Comprehension REF: p. 203|p. 205

DIF: Cognitive Level: Application REF: p. 204

DIF: Cognitive Level: Application REF: pp. 204-205

DIF: Cognitive Level: Application REF: p. 205

DIF: Cognitive Level: Application REF: p. 205

DIF: Cognitive Level: Application REF: p. 205

DIF: Cognitive Level: Analysis REF: p. 206

DIF: Cognitive Level: Analysis REF: p. 207

DIF: Cognitive Level: Analysis REF: p. 207

DIF: Cognitive Level: Analysis REF: p. 213|p. 215

DIF: Cognitive Level: Application REF: p. 212

DIF: Cognitive Level: Comprehension REF: p. 206

DIF: Cognitive Level: Application REF: p. 211

DIF: Cognitive Level: Application REF: p. 224

DIF: Cognitive Level: Application REF: p. 229

DIF: Cognitive Level: Comprehension REF: p. 226

DIF: Cognitive Level: Analysis REF: p. 221|p. 223

DIF: Cognitive Level: Comprehension REF: p. 226

19. Which is the most critical element of pediatric emergency care?

DIF: Cognitive Level: Application REF: p. 206|p. 211

DIF: Cognitive Level: Analysis REF: p. 226

DIF: Cognitive Level: Analysis REF: p. 221

DIF: Cognitive Level: Analysis REF: p. 207

DIF: Cognitive Level: Knowledge REF: p. 209

DIF: Cognitive Level: Application REF: p. 211

DIF: Cognitive Level: Comprehension REF: p. 214

DIF: Cognitive Level: Comprehension REF: p. 216

DIF: Cognitive Level: Comprehension REF: p. 212

DIF: Cognitive Level: Application REF: p. 214

DIF: Cognitive Level: Application REF: p. 211

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