710 CHAPTER 35 Child Health Nursing
Child Health Nursing
35 Review Questions with Answers
CHAPTER
and Rationales
QUESTIONS
Note: Thousands of additional practice questions are available
on the enclosed companion CD.
Questions generally are grouped by content and usually when it
is first evident within a particular developmental level. Therefore,
there will be some questions with children whose age is not
specific to the broad classification of infants, toddlers, preschool-
rs
ers, or adolescents.
Nursing Care of Infants
nu
1. The parents of a child call the clinic and tell the nurse that
u their child is irritable and has a 102° F temperature after
having had a routine immunization. The clinic protocol
l_
indicates acetaminophen 15 mg/kg is to be administered
every 4 to 6 hours. The child’s last weight was 9.6 kg. The
parent states, “The bottle of acetaminophen says that there
are 160 mg in 5 mL.” How much should the nurse tell the
ca
parent to administer for each dose? Record your answer
using one decimal place.
Answer: __________ mL
2. A family has decided to withhold “extraordinary care” for a
i
newborn with severe abnormalities. How should the nurse
in
interpret this decision?
1. The newborn has no rights.
2. It is the same as euthanasia.
3. It is illegal professional practice.
cl
4. The newborn is being allowed to die.
3. A nurse is planning an initial home care visit to a mother
who gave birth to a high-risk infant. For what time of day
@
should the nurse schedule the visit for it to be most
productive?
1. When the husband is out of the home.
2. At a time the mother is feeding the infant.
3. At a time that is convenient for the family.
4. When the nurse can spend time with the family.
4. What is the first action a nurse should take before admin-
istering a tube feeding to an infant?
1. Irrigate the tube with water.
2. Offer a pacifier to the infant.
3. Slowly instill 10 mL of formula.
4. Place the infant in the Trendelenburg position.
5. Which nursing intervention provides the most support
to the parents of an infant with an obvious physical
anomaly?
710 u Denotes alternate format question.
g
1. Encourage them to express their concerns.
in
2. Discourage them from talking about their baby.
3. Assure them not to worry because the anomaly can be
repaired.
4. Show them postoperative photographs of infants who
had similar anomaly.
6. When picked up by a parent or the nurse, an 8-month-old
infant screams and seems to be in pain. After observing this
behavior, what should the nurse discuss with the parent?
1. Accidents and the importance of their prevention
2. Limiting play time with other children in the family
3. Any other behaviors that the parent may have noticed
4. Food and specific vitamins that should be given to infants
7. A 1-week-old infant has been in the pediatric unit for 18
hours following placement of a spica cast. The nurse observes
a respiratory rate of fewer than 24 breaths/min. No other
changes are noted. Because the infant is apparently well, the
nurse does not report or documentation the slow respiratory
rate. Several hours later, the infant experiences severe respira-
tory distress and emergency care is necessary. What should
be considered if legal action is taken?
1. Most infants’ respirations are slow when they are
uncomfortable.
2. The respirations of young infants are irregular, so a drop
in rate is unimportant.
3. Vital signs that are outside the expected parameters are
significant and should be documented.
4. The respiratory tract of young infants is underdeveloped,
and their respiratory rate is not significant.
8. What suggestions should a nurse give to a parent to help a
u 2-month-old infant who has colic? Select all that apply.
1. Give smaller, more frequent feedings.
2. Burp frequently when giving a feeding.
3. Place a warm heating pad on the abdomen.
4. Offer warm, sweetened tea when crying begins.
5. Rock the baby gently in a quiet room when crying
begins.
9. A nurse at the well-child clinic determines a 1-year-old
u infant’s length to be below what is expected. The current
height is 28 inches, and the birth length was 20 inches.
What should this infant’s current length be? Record your
answer using a whole number.
Answer: _____________ inches

10. What nursing intervention best meets a major developmen-
tal need of a newborn in the immediate postoperative
period?
1. Giving a pacifier to the infant
2. Putting a mobile over the infant’s crib
3. Providing the infant with a soft, cuddly toy
4. Warming the infant’s formula before feeding
11. What characteristics does a nurse expect infants and young
u children who have failure to thrive to exhibit? Select all that
apply.
1. Hyperactivity
2. Language deficit
3. Being overweight
4. Proneness to illness
5. Responsiveness to stimuli
12. A parent and 3-month-old infant are visiting the well-baby
clinic for a routine examination. What should the nurse
include in the accident prevention teaching plan?
1. Remove small objects from the floor.
rs
2. Cover electric outlets with safety plugs.
3. Remove toxic substances from low areas.
4. Test the temperature of water before bathing.
13. A nurse is teaching a parent how to prevent accidents while
emphasized about the infant’s motor development?
1. Sits up
2. Rolls over
nu
caring for a 6-month-old infant. What ability should be
l_
3. Crawls short distances
4. Stands while holding on to furniture
14. A 7-month-old girl is to be catheterized to obtain a sterile
urine specimen. One of the infant’s parents expresses fear
ca
that this procedure may traumatize the baby psychologically.
How should the nurse provide reassurance?
1. The fear is justified and the nurse should obtain a “clean
catch” specimen.
i
2. Parents have a right to refuse the catheterization and the
in
concerns are realistic.
3. Although the concern is appropriate, the need for a
sterile specimen is the priority.
4. The procedure is uncomfortable, but there should not
cl
be a damaging long-term effect.
15. A nurse is assessing the oral cavity of a 6-month-old infant.
The parent asks which teeth will erupt first. How should the
@
nurse respond?
1. Incisors
2. Canines
3. Upper molars
4. Lower molars
16. A nurse is teaching a class of new parents about how to
position their infants during the first few weeks of life.
Which position is safest?
1. On the back, lying flat
2. On either side, lying flat
3. Head slightly elevated on the left side
4. Head slightly elevated on the right side
17. A parent arrives in the emergency clinic with a 3-month-old
baby who says, “My baby stopped breathing for a while.”
The infant continues to have difficulty breathing, with
Review Questions 711
prolonged periods of apnea. Which assessment data should
alert the nurse to suspect shaken baby syndrome (SBS)?
1. Birth occurred before 32 weeks’ gestation
2. Lack of stridor and adventitious breath sounds
3. Previous episodes of apnea lasting 10 to 15 seconds
4. Retractions and use of accessory respiratory muscles
18. Parents of a sick infant talk with a nurse about their baby.
One parent says, “I am so upset; I didn’t realize our baby
was ill.” What major indication of illness in an infant should
the nurse explain to the parent?
1. Grunting respirations
2. Excessive perspiration
3. Longer periods of sleep
4. Crying immediately after feedings
g
19. A newborn is admitted to the neonatal intensive care unit
(NICU) with choanal atresia. Which part of the infant’s
in
body should the nurse assess?
1. Rectum
2. Nasopharynx
3. Intestinal tract
4. Laryngopharynx
20. What behavior does the nurse anticipate while feeding a
newborn with choanal atresia?
1. Chokes on the feeding
2. Has difficulty swallowing
3. Does not appear to be hungry
4. Takes about half of the feeding
21. An infant is admitted to the pediatric intensive care unit
u (PICU) after open-heart surgery for the repair of a ventricu-
lar septal defect. Place these nurse assessments in order of
priority.
1. _____ Heart rate
2. _____ Operative site
3. _____ Urinary output
4. _____ Respiratory status
5. _____ Intravenous catheter
22. What is the nurse’s priority intervention when preparing for
admission of a child with acute laryngotracheobronchitis?
1. Pad the side rails of the crib.
2. Arrange for a quiet, cool room.
3. Place a tracheotomy set at the bedside.
4. Obtain a recliner so that a parent can stay.
23. What should be the nurse’s priority action when caring for
a child with acute laryngotracheobronchitis?
1. Initiate measures to reduce fever.
2. Ensure delivery of humidified oxygen.
3. Provide support to reduce apprehension.
4. Continually assess the respiratory status.
24. A 3-month-old infant has been hospitalized with respiratory
syncytial virus (RSV). What is the priority intervention?
1. Administering an antiviral agent
2. Clustering care to conserve energy
3. Offering oral fluids to promote hydration
4. Providing an antitussive agent whenever necessary
25. The health care provider prescribes 375 mg ampicillin IV
u q6h for a 5-month-old with recurring respiratory infections.
The drug is supplied as 500 mg of powder in a vial. The
directions state to mix the powder with 1.8 mL diluent,
712 CHAPTER 35 Child Health Nursing

which yields 250 mg/mL. How many milliliters should the 33. A nurse is performing a physical examination on an infant
nurse administer? Record your answer using one decimal with Down syndrome. For what anomaly should the nurse
place. assess the child?
Answer: __________ mL 1. Bulging fontanels
26. A child is admitted to the hospital with pneumonia. What 2. Stiff lower extremities
is the priority need that must be included in the nursing 3. Abnormal heart sounds
plan of care for this child? 4. Unusual pupillary reactions
1. Rest 34. A parent tells the nurse, “My 9-month-old baby no longer
2. Exercise has the same strong grasp that was present at birth and no
3. Nutrition longer acts startled by loud noises.” How should the nurse
4. Elimination explain these changes in behavior?
27. A 6-month-old infant is brought to the emergency depart- 1. “I will check these responses before deciding how to
ment in severe respiratory distress. A diagnosis of respiratory proceed.”
syncytial virus (RSV) is made and the infant is admitted to 2. “Failure of these responses may be related to a develop-

g
the pediatric unit. What should be included in the nursing mental delay.”
plan of care? 3. “Additional sensory stimulation is needed to aid in the

in
1. Place in a warm, dry environment. return of these responses.”
2. Allow parents and siblings to visit. 4. “These responses are replaced by voluntary activity at
3. Maintain standard and contact precautions. about five months of age.”

rs
4. Administer prescribed antibiotic immediately. 35. The nurse is teaching a group of parents about the side
28. An infant is admitted to the neonatal intensive care unit effects of the immunization vaccines. Which sign should the
(NICU) with exstrophy of the bladder. What covering nurse include when talking about an infant receiving the
should the nurse use to protect the exposed area? Haemophilus influenzae (Hib) vaccine?
1. Loose diaper
2. Dry gauze dressing
3. Moist sterile dressing
4. Petroleum jelly gauze pad
nu 1. Lethargy
2. Urticaria
3. Generalized rash
4. Low-grade fever
l_
29. An additional defect is associated with exstrophy of the 36. An infant is receiving parenteral therapy. The IV orders are
bladder. For what anomaly should the nurse assess the u 400 mL of D5W 0.45% sodium chloride to run over 8
infant? hours. At what rate should the nurse maintain the hourly
1. Imperforate anus rate? Record your answer using a whole number.
ca

2. Absence of one kidney Answer: ____________ mL

3. Congenital heart disease 37. An infant who has had diarrhea for 3 days is admitted in a
4. Pubic bone malformation lethargic state and is breathing rapidly. The parent states that
30. A nurse is caring for an infant born with exstrophy of the the baby has been ingesting formula, although not as much
i

bladder. What does the nurse determine is the greatest risk as usual, and cannot understand the sudden change. What
in

for this infant? explanation should the nurse give the parent?
1. Infection 1. Cellular metabolism is unstable in young children.
2. Dehydration 2. The proportion of water in the body is less than in adults.
3. Urinary retention 3. Renal function is immature in children until they reach
cl

4. Intestinal obstruction school age.

31. A home care nurse is visiting a family for the first time. The 4. The extracellular fluid requirement per unit of body
4-week-old infant had surgery for exstrophy of the bladder weight is greater than in adults.
@

and creation of an ileal conduit soon after birth. When the
nurse arrives, the mother appears tired and the baby is
crying. After an introduction, which is the most appropriate
statement by the nurse?
1. “Tell me about your daily routine.”
2. “You look tired. Is everything all right?”
3. “When was the last time the baby had a bottle?”
4. “Oh, it looks like you two are having a bad day.”
32. The nurse is teaching a parent group about the reason for
adhering to the immunization schedule. What complication
of mumps is important for adolescents to avoid?
1. Sterility
2. Hypopituitarism
3. Decrease in libido
4. Decrease in androgens
38. When explaining the occurrence of febrile seizures to a
parents’ class, what information should the nurse include?
1. They may occur in minor illnesses.
2. The cause is usually readily identified.
3. They usually do not occur during the toddler years.
4. The frequency of occurrence is greater in females than
males.
39. A parent tells the nurse in the emergency department, “My
3-year-old has had a fever for several days and has been
vomiting.” After instituting ordered measures to reduce the
fever, what nursing action is most important?
1. Preventing shivering
2. Restricting oral fluids
3. Measuring output hourly
4. Taking vital signs hourly

40. The nurse observes that a 3-year-old child in a crib has a
clamped jaw and is having a tonic-clonic seizure. What is
the priority nursing responsibility at this time?
1. Apply restraints.
2. Administer oxygen.
3. Protect the child from self-injury.
4. Insert a plastic airway in the child’s mouth.
41. A child sitting on a chair in a playroom starts to have a
tonic-clonic seizure with a clenched jaw. What is the nurse’s
best initial action?
1. Attempt to open the jaw.
2. Place the child on the floor.
3. Call out for assistance from staff.
4. Place a pillow under the child’s head.
42. A nurse is caring for a child with the diagnosis of meningitis.
u What clinical findings indicate an increase in intracranial
pressure? Select all that apply.
1. Irritability
2. Bradycardia
rs
3. Hyperalertness
4. Decreased pulse pressure
5. Decreased systolic blood pressure
43. An infant is diagnosed with communicating hydrocephalus.
respond? nu
The parents ask for clarification of the health care provider’s
explanation of their baby’s problem. How should the nurse
1. “Too much spinal fluid is produced within the spaces
l_
(ventricles) of the brain.”
2. “The flow of spinal fluid through the brain cells does not
empty effectively into the spinal cord.”
3. “The spinal fluid is prevented from adequate absorp
ca
tion by a blockage in the spaces (ventricles) of the
brain.”
4. “There is a part of the brain surface that usually absorbs
spinal fluid after its production that is not functioning
i
adequately.”
in
44. A 6-week-old infant and the mother arrive in the emergency
department via ambulance. The father arrives several minutes
later with two children, 7 and 9 years old. The infant is not
breathing, and the eventual diagnosis is sudden infant death
cl
syndrome (SIDS). The parents take turns holding the infant
in another room. The nurse remains present and provides
emotional support to the parents. What is an important
@
short-term goal for this family?
1. Identify the problems that they will be facing related to
the loss of the infant.
2. Include the infant’s siblings in the events and grieving
following the infant’s death.
3. Seek out other families who have lost infants to SIDS
and receive support from them.
4. Accept that there was nothing that they should have
done to prevent the infant’s death.
45. What should be included in the nursing care of an infant
with increased intracranial pressure?
1. Weigh daily before feeding.
2. Elevate the head higher than the hips.
3. Check the reflexes at regular intervals.
4. Monitor alertness with frequent stimulation.
Review Questions 713
46. The parents of an infant who just had a ventriculoperitoneal
shunt inserted for hydrocephalus are concerned about the
prognosis. What information should the nurse give the
parents?
1. The prognosis is excellent and the valve is permanent.
2. The shunt may need to be revised as the child grows
older.
3. If any brain damage has occurred, it is irreversible even
after the first year of life.
4. Hydrocephalus usually is self-limiting by 2 years of age,
and then the shunt is removed.
47. An infant who was born with a meningomyelocele develops
hydrocephalus. A ventriculoperitoneal shunt is inserted.
What nursing intervention is essential in this infant’s care
g
during the first 24 hours after surgery?
1. Placing in high-Fowler position
in
2. Administering the prescribed sedative
3. Positioning on the same side as the shunt
4. Monitoring for increasing intracranial pressure
48. The discharge of a newborn with a surgically repaired myelo-
meningocele is anticipated at about 2 weeks of age. What
teaching should the nurse include when preparing the
parents for the discharge?
1. Demonstration of restrictive positions to prevent the
infant from turning
2. Discussion about the need to limit the infant’s fluid
intake to formula only
3. Instructions on how to do passive range-of-motion exer-
cises to the infant’s lower extremities
4. Explanation of the need to provide the infant with a
quiet environment to reduce external stimuli
­
49. An infant who had a revision of a ventriculoperitoneal shunt
u is diagnosed with meningitis from an infected shunt. What
clinical manifestations support this conclusion? Select all
that apply.
1. Fever
2. Lethargy
3. Stiff neck
4. Poor feeding
5. Depressed fontanels
50. A nurse in the pediatric clinic is assessing an infant who had
a revision of a ventriculoperitoneal shunt. What clinical
finding alerts the nurse that intracranial pressure has
increased?
1. Increased pulse rate
2. Hypoactive reflexes
3. Decreased blood pressure
4. Tension of the anterior fontanel
51. The parents of an infant who has had a surgical repair of a
myelomeningocele express concern about skin care and ask
what they can do to avoid problems. The nurse should teach
the parents that their infant:
1. will require long-term multidisciplinary follow-up care.
2. should take prophylactic antibiotic therapy indefinitely.
3. must be kept dry by applying powder after each diaper
change.
4. does not need anything more than routine cleansing and
diaper changes.
714 CHAPTER 35 Child Health Nursing
52. What is the primary nursing intervention for an infant with
a myelomeningocele before surgical correction?
1. Minimize infection.
2. Prevent trauma to the sac.
3. Observe for increasing paralysis.
4. Assess the degree of bowel and bladder control.
53. An infant with a myelomeningocele is admitted to the pedi-
atric intensive care unit (PICU). While the infant is awaiting
surgical correction of the defect, what is the most appropri-
ate nursing intervention?
1. Using disposable diapers
2. Placing the infant in the prone position
3. Performing neurologic checks above the site of the lesion
4. Washing the area below the defect with a nontoxic
antiseptic
54. After closure of a newborn’s myelomeningocele, what essen-
tial nursing intervention must be included in the plan of
care?
1. Limiting leg movement
rs
2. Decreasing environmental stimuli
3. Measuring head circumference daily
4. Observing for serous drainage from the nares
55. A nurse is caring for an infant with bacterial meningitis.
The parents ask how their baby could have contracted
the illness. What does the nurse consider as the most
nu
likely route of transmission to the central nervous system
(CNS)?
l_
1. Genitourinary tract
2. Gastrointestinal tract
3. Skin or mucous membranes
4. Cranial apertures or sinuses
ca
56. The nurse is admitting an 8-month-old infant to the hospital
u because bacterial meningitis is suspected. List in order of
priority the nursing actions that should be taken.
1. _____ Institute respiratory isolation.
i
2. _____ Assist with a lumbar puncture.
in
3. _____ Insert a circulatory access device.
4. _____ Administer prescribed antibiotics.
5. _____ Monitor for signs of nuchal rigidity
57. For how long should a nurse maintain isolation of a child
cl
with bacterial meningitis?
1. For 12 hours after admission
2. Until the cultures are negative
@
3. Until antibiotic therapy is completed
4. For 48 hours after antibiotic therapy begins
58. A 1-year-old infant has been admitted with a tentative diag-
nosis of bacterial meningitis. A lumbar puncture is per-
formed to confirm the diagnosis. What laboratory report of
the spinal fluid supports this diagnosis?
1. Decreased cell count
2. Elevated protein level
3. Increased glucose level
4. Low spinal fluid pressure
59. A nurse is caring for a child with meningococcal meningitis.
What clinical finding does the nurse expect when perform-
ing a physical assessment?
1. Severe glossitis
2. Low-grade fever
3. Purpuric skin rash
4. Tremors of the extremities
60. A nurse is caring for a 2-year-old child with meningitis. For
u which clinical manifestations of increasing intracranial pres-
sure should the nurse assess the child? Select all that apply.
1. Seizures
2. Vomiting
3. Bulging fontanels
4. Subnormal temperature
5. Decreased respiratory rate
61. What does a nurse determine is the most serious complica-
tion of meningitis in young children?
1. Epilepsy
2. Blindness
g
3. Peripheral circulatory collapse
4. Communicating hydrocephalus
in
62. The nurse observes that an infant has asymmetric gluteal
folds. For which disorder should the nurse perform a focused
assessment?
1. Congenital inguinal hernia
2. Central nervous system damage
3. Peripheral nervous system damage
4. Developmental dysplasia of the hip
63. A 3-month-old infant with severe developmental dysplasia
of the hip has a hip spica cast applied. What should the
nurse teach the parents to prevent a serious complication?
1. Change diapers frequently.
2. Decrease the number of feedings per day.
3. Avoid turning from prone to supine positions.
4. Call the health care provider if there is a foul smell.
64. A 4-month-old infant had a spica cast applied. What should
the nurse include in the discharge instructions to the parents?
1. Obtain a specially designed car seat.
2. Keep diapers on to prevent soiling of the cast.
3. Change the infant’s position every eight hours.
4. Use the bar between the infant’s legs to change
positions.
65. What procedure should a nurse use when elevating the head
of an infant in a spica cast?
1. Change this position after an hour.
2. Place pillows under the shoulders.
3. Pad the edge of the cast with folded diapers.
4. Raise the entire mattress at the head of the crib.
66. A nurse is caring for a 3-month-old infant who is diagnosed
with congenital hypothyroidism. What should the parents
be told of the probable effect on the infant’s future if treat-
ment is not begun immediately?
1. Myxedema
2. Thyrotoxicosis
3. Spastic paralysis
4. Mental retardation
67. At a visit to the well-baby clinic, the parents are upset
because their 9-month-old infant has a severe diaper rash;
one parent wants to know how to treat it and prevent it from
recurring. What cause of diaper dermatitis should the nurse
include when answering the parent’s question?
1. Use of disposable diapers
2. Prolonged contact with an irritant

3. Decreased pH of the infant’s urine
4. Too early introduction of solid foods
68. A parent brings a 2-week-old infant to the clinic because the
infant continually regurgitates. Chalasia, an incompetent
cardiac sphincter, is suspected. What instructions should the
nurse give the parent?
1. Keep the infant in an upright position after feedings.
2. Prevent the infant from crying for prolonged periods.
3. Keep the infant in the prone position following
feedings.
4. Ensure that the infant drinks a full bottle of formula at
each feeding.
69. A parent brings a 9-month-old infant to the pediatric clinic
and asks about the introduction of new foods. What should
the nurse suggest?
1. “Mix the pureed food with formula and offer it in a
bottle.”
2. “Give the entire regular feeding and then introduce the
new food.”
rs
3. “Offer a new food every day until one is accepted and
then offer it again.”
4. “Give a small amount of formula and then offer the new
food while still hungry.”
70.
repair of a cleft lip include?
1. Preventing crying
2. Placing in a semi-Fowler position
nu
What should nursing care for an infant after the surgical
l_
3. Keeping NPO for 1 day after surgery
4. Feeding with a spoon for 2 days after surgery
71. A nurse who is caring for an infant with a cleft lip is con-
cerned about preventing an infection. Why does the cleft lip
ca
predispose the infant to infection?
1. Waste products accumulate along the defect.
2. There is inadequate circulation in the defective area.
3. Nutrition is inadequate because of ineffective feeding.
i
4. Mouth breathing dries the oropharyngeal mucous
in
membranes.
72. What should a nurse use to feed an infant born with a
unilateral cleft lip and palate?
1. Plastic spoon
cl
2. Cross-cut nipple
3. Parenteral infusion
4. Rubber-tipped syringe
@
73. A parent of an 11-month-old infant who has a cleft palate
asks the nurse why it was recommended that closure of the
palate should be done before the age of 2. How should the
nurse respond?
1. “After age 2 surgery is frightening and should be avoided
if possible.”
2. “Eruption of the 2-year molars often complicates the
surgical procedure.”
3. “As your child gets older, the palate gets wider and
more difficult to repair.”
4. “Surgery should be performed before your child starts to
use faulty speech patterns.”
74. An infant has a cleft lip and palate and is admitted to the
u hospital for a surgical repair. Place the nurse’s postoperative
interventions in order of priority.
Review Questions 715
1. _____ Preventing vomiting
2. _____ Maintaining a patent airway
3. _____ Assessing the infant’s hearing status
4. _____ Monitoring parenteral fluid infusions
5. _____ Teaching the parents alternate feeding methods
75. An infant with hypertrophic pyloric stenosis (HPS) is admit-
ted to the pediatric unit. What does the nurse expect when
palpating the infant’s abdomen?
1. A distended colon
2. Marked tenderness around the umbilicus
3. An olive-sized mass in the right upper quadrant
4. Rhythmic peristaltic waves in the lower abdomen
76. A nurse is caring for an infant with a tentative diagnosis of
hypertrophic pyloric stenosis (HPS). What is most impor-
g
tant for the nurse to assess?
1. Quality of the cry
in
2. Signs of dehydration
3. Coughing up of feedings
4. Characteristics of the stool
77. Surgery to correct hypertrophic pyloric stenosis (HPS) is
performed on a 3-week-old infant who had been formula-
fed. Which postoperative feeding order is appropriate?
1. Thickened formula 24 hours after surgery
2. Withholding feedings for the first 24 hours
3. Regular formula feeding within 24 hours after surgery
4. Additional glucose feedings as desired after first 24
hours
78. Corrective surgery for hypertrophic pyloric stenosis (HPS)
is completed, and the infant is returned to the pediatric unit
with an IV infusion in place. What is the priority nursing
action?
1. Apply adequate restraints.
2. Administer a mild sedative.
3. Assess the IV site for infiltration.
4. Attach the nasogastric tube to wall suction.
79. An infant had corrective surgery for hypertrophic pyloric
stenosis (HPS). What should the nurse teach a parent to do
immediately after a feeding to limit vomiting?
1. Rock the infant.
2. Place the infant in an infant seat.
3. Place the infant flat on the right side.
4. Keep the infant awake with sensory stimulation.
80. A newborn with an anorectal anomaly had an anoplasty
performed. At the 2-week follow-up visit, a series of anal
dilations are begun. What should the nurse recommend to
the parents to help prevent the infant from becoming
constipated?
1. Use a soy formula.
2. Breastfeed if possible.
3. Administer a suppository nightly.
4. Offer glucose water between feedings.
81. A nurse is caring for an infant with phenylketonuria (PKU).
What diet should the nurse anticipate will be ordered by the
health care provider?
1. Fat-free
2. Protein-enriched
3. Phenylalanine-free
4. Low-phenylalanine
716 CHAPTER 35 Child Health Nursing

82. What should the nurse include in the teaching plan
for parents of an infant diagnosed with phenylketonuria
(PKU)?
1. Mental retardation occurs if PKU is untreated. 89.
2. Testing for PKU is done immediately after birth.
3. Treatment for PKU includes lifelong medications.
4. PKU is transmitted by an autosomal dominant gene.
83. The parents of a newborn with phenylketonuria (PKU) need
help and support in adhering to specific dietary restrictions.
They ask the nurse, “How long will our child have to be on
this diet?” How should the nurse respond?
1. “We still are not sure; you should discuss this with your 90.
health care provider.”
2. “If your baby does well, foods containing protein can
3. It could increase the fear of intrusive procedures.
4. The result could cause shock from a sudden drop in
temperature.
An order is written for an isotonic enema for a 2-year-old
child. What is the maximum amount of fluid the nurse
should administer without a specific order from the health
care provider?
1. 100 to 150 mL
2. 155 to 250 mL
3. 255 to 360 mL
4. 365 to 500 mL
A 5-month-old infant develops severe diarrhea and is given
IV fluids. What is the rationale for the nurse to closely
monitor the IV flow rate?

g
gradually be introduced.” 1. Limiting output
3. “Your child needs to be on this diet at least through 2. Replacing lost fluids

in
adolescence and into adulthood.” 3. Avoid IV infiltration
4. “This is a lifelong problem, and it is recommended that 4. Preventing cardiac overload
dietary restrictions must be continued.” 91. What is an essential nursing action when caring for a young

rs
84. A nurse plans to discuss childhood nutrition with a group child with severe diarrhea?
of parents whose children have Down syndrome in an 1. Maintain the IV.
attempt to minimize a common nutritional problem. What 2. Take daily weights.
problem should be addressed? 3. Replace the lost calories.
1. Rickets
2. Obesity
3. Anemia
4. Rumination
nu 92.
4. Promote perianal skin integrity.
A nurse is caring for an infant whose vomiting is intractable.
For what complication is it most important for the nurse to
assess?
l_
85. A nurse is caring for a 3-month-old infant whose abdomen 1. Acidosis
u is distended and whose vomitus is bile stained. The nurse 2. Alkalosis
suspects an intestinal obstruction. What clinical manifesta- 3. Hyperkalemia
tions support this suspicion? Select all that apply. 4. Hypernatremia
ca

1. Weak pulse 93. A nurse is administering IV fluids to a dehydrated infant.

2. Hypotonicity What intervention is most important at this time?
3. Paroxysmal pain 1. Continuing the prescribed flow rate
4. High-pitched cry 2. Monitoring the intravenous drop rate
i

5. Grunting respirations 3. Calculating the total necessary intake

in

86. A nurse is discussing the care of an infant with colic with 4. Maintaining the fluid at body temperature
the parents. What should the nurse explain is the cause of 94. A 5-month-old infant is brought to the pediatric clinic for
colicky behavior? a routine monthly examination. What assessment alerts the
1. Inadequate peristalsis nurse to notify the health care provider?
cl

2. Paroxysmal abdominal pain 1. Temperature of 99.5° F

3. An allergic response to certain proteins in milk 2. Blood pressure of 75/48 mm Hg
4. A protective mechanism designed to eliminate foreign 3. Heart rate of 100 beats per minute
@

proteins 4. Respiratory rate of 50 breaths per minute

87. A 1-month-old infant is admitted to the pediatric unit with 95. A nurse is reviewing the clinical records of infants and
a tentative diagnosis of Hirschsprung disease (congenital children with cardiac disorders who developed heart
aganglionic megacolon). What procedure does the nurse failure. What did the nurse determine is the last sign of heart
expect to be used to confirm the diagnosis? failure?
1. Colonoscopy 1. Tachypnea
2. Rectal biopsy 2. Tachycardia
3. Multiple saline enemas 3. Peripheral edema
4. Fiberoptic nasoenteric tube 4. Periorbital edema
88. A health care provider orders a tap water enema for 96. What is a common finding that the nurse can identify in
a 6-month-old infant with suspected Hirschsprung most children with symptomatic cardiac malformations?
disease. What rationale causes the nurse to question the 1. Mental retardation
order? 2. Inherited genetic factors
1. The result could be loss of necessary nutrients. 3. Delayed physical growth
2. It could cause a fluid and electrolyte imbalance. 4. Clubbing of the fingertips

97. A 1-year-old child has a congenital cardiac malformation
that causes right-to-left shunting of blood through the heart.
What clinical finding should the nurse expect?
1. Proteinuria
2. Peripheral edema
3. Elevated hematocrit
4. Absence of pedal pulses
98. The parents of a child who is scheduled for open-heart
surgery ask why their child must be subjected to chest tubes
after surgery. What should the nurse consider before
responding in language the parents will understand?
1. They will increase tidal volumes.
2. Drainage of air and fluid will be facilitated.
3. They will maintain positive intrapleural pressure.
4. Pressure on the pericardium and chest wall will be
regulated.
99. After a discussion with the health care provider, the parents
of an infant with patent ductus arteriosus (PDA) ask the
nurse to explain once again what PDA is. How should the
rs
nurse respond?
1. The diameter of the aorta is enlarged.
2. The wall between the right and left ventricles is open.
3. It is a narrowing of the entrance to the pulmonary artery.
aorta.
nu
4. It is a connection between the pulmonary artery and the
100. A nurse is caring for a child with a cardiac malformation
associated with left-to-right shunting. What does the nurse
l_
consider to be the major characteristic of this type of con-
genital disorder?
1. Elevated hematocrit
2. Severe growth retardation
ca
3. Clubbing of the fingers and toes
4. Increased blood flow to the lungs
101. A young child has coarctation of the aorta. What does
the nurse expect to identify when taking the child’s vital
i
signs?
in
1. A weak radial pulse
2. An irregular heartbeat
3. A bounding femoral pulse
4. An elevated radial blood pressure
cl
102. A 2-week-old infant is admitted with a tentative diagnosis
of a ventricular septal defect. The parents report that their
baby has had difficulty feeding since coming home after the
@
birth. What should the nurse consider before responding?
1. Feeding problems are common in neonates.
2. Inadequate sucking is not significant in the absence of
cyanosis.
3. Ineffective sucking and swallowing may be early indica-
tions of a heart defect.
4. Many neonates retain mucus, and this may interfere with
feeding for several weeks.
103. A 3-year-old child is scheduled for a cardiac catheterization.
What is the priority nursing care after this procedure?
1. Encouraging early ambulation
2. Monitoring the site for bleeding
3. Restricting fluids until the blood pressure is stabilized
4. Comparing the blood pressure of both lower
extremities
Review Questions 717
104. A parent brings a 2-month-old infant with Down syndrome
to the pediatric clinic for a physical and administration of
immunizations. The nurse performs an initial physical
assessment. Which clinical finding should alert the nurse to
perform a further assessment?
1. Flat occiput
2. Small, low-set ears
3. Circumoral cyanosis
4. Protruding furrowed tongue
105. Which cardiac defects are associated with tetralogy of Fallot?
1. Right ventricular hypertrophy, atrial and ventricular
defects, and mitral valve stenosis
2. Origin of the aorta from the right ventricle and of the
pulmonary artery from the left ventricle
g
3. Right ventricular hypertrophy, ventricular septal defect,
pulmonic stenosis, and overriding aorta
in
4. Altered connection between the pulmonary artery and
the aorta, right ventricular hypertrophy, and an atrial
septal defect
106. A nurse is reviewing the laboratory report of a child with
tetralogy of Fallot that indicates an elevated RBC count.
What does the nurse identify as the cause of the
polycythemia?
1. Low blood pressure
2. Tissue oxygen needs
3. Diminished iron level
4. Hypertrophic cardiac muscle
107. What clinical manifestation of tetralogy of Fallot should the
nurse expect when caring for children with this diagnosis?
1. Slow respirations
2. Clubbing of fingers
3. Decreased RBC counts
4. Subcutaneous hemorrhages
108. A child undergoes heart surgery to repair the defects associ-
ated with tetralogy of Fallot. What behavior is essential for
the nurse to prevent postoperatively?
1. Crying
2. Coughing
3. Straining at stool
4. Unnecessary movement
109. An infant who had cardiac surgery for a congenital defect is
to be discharged. What should the nurse emphasize to the
parents when they administer the prescribed antibiotic?
1. Give the antibiotic between feedings.
2. Ensure that the antibiotic is administered as prescribed.
3. Shake the bottle thoroughly before giving the
antibiotic.
4. Keep the antibiotic in the refrigerator after the bottle has
been opened.
110. An infant with a congenital heart defect is being given
gavage feedings. The parents ask the nurse why this is neces-
sary. How should the nurse respond?
1. “It limits the chance of vomiting.”
2. “It allows the feeding to be administered rapidly.”
3. “The energy that would have been expended on sucking
is conserved.”
4. “The quantity of nutritional liquid can be regulated
better than with a bottle.”
718 CHAPTER 35 Child Health Nursing
111. The parents of a 6-week-old infant who was born without
an immune system ask a nurse why their baby is still so
healthy. How should the nurse reply?
1. Exposure to pathogens during this time can be
limited.
2. Some antibodies are produced by the infant’s colonic
bacteria.
3. Antibodies are passively received from the mother
through the placenta and breast milk.
4. Fewer antibodies are produced by the fetal thymus
during the eighth and ninth months of gestation.
112. When evaluating the laboratory report of a 1-year-old
infant’s hematocrit, a nurse compares it with the expected
hematocrit range for this age group. What is the hematocrit
of a healthy12-month-old infant?
1. 19% to 32%
2. 29% to 41%
3. 37% to 47%
4. 42% to 69%
rs
113. What explanation should the nurse give a parent about the
purpose of a tetanus toxoid injection for her child?
1. Passive immunity is conferred for life.
2. Long-lasting active immunity is conferred.
3. Lifelong active natural immunity is conferred.
4. Passive natural immunity is conferred temporarily.
nu
114. The parents of a 4-year-old child who is receiving predni-
u SONE asks a nurse why some of the booster immunizations
l_
are being postponed. The nurse explains that administering
live attenuated virus vaccines is contraindicated for children
receiving corticosteroids because they make them more sus-
ceptible to infection. Which are safe for the child to receive?
ca
Select all that apply.
1. Rubeola
2. Pertussis
3. Varicella
i
4. Inactivated poliovirus
in
5. Tetanus immune globulin
115. A school nurse is teaching parents of school-age children
about the importance of immunizations for the childhood
communicable diseases. What preventable disease may cause
cl
the complication of encephalitis?
1. Varicella
2. Scarlet fever
@
3. Poliomyelitis
4. Whooping cough
116. A parent asks a nurse how to tell the difference between
measles (rubeola) and German measles (rubella). What
should the nurse tell the parent about rubeola that is differ-
ent from rubella?
1. High fever and Koplik spots
2. Rash on the trunk with pruritus
3. Nausea, vomiting, and abdominal cramps
4. Characteristics of a cold, followed by a rash
117. The parents of an infant ask the nurse why their baby is
scheduled to receive the intramuscular polio vaccine rather
than the oral vaccine. What is the nurse’s best response?
1. “The American Academy of Pediatrics recommends the
intramuscular vaccine because it is safer.”
2. “The consensus is that either can be used, since both
produce the same results and are equally safe.”
3. “The oral vaccine is more expensive, so the intramuscular
vaccine is preferred unless it is contraindicated.”
4. “The U.S. Centers for Disease Control and Prevention
recommends the intramuscular vaccine unless the infant
or a family member is immunocompromised.”
118. A nurse is teaching parents about why most children should
be immunized against varicella (chickenpox) and why some
receiving specific medications should not. Which medica-
tion should be included in the discussion?
1. Insulin
2. Steroids
3. Antibiotics
g
4. Anticonvulsants
119. A nurse is teaching a class about immunizations to members
in
of a grammar school’s Parent-Teachers Association. Which
childhood disease is the nurse discussing when explaining
that it is a viral disease that starts with malaise and a highly
pruritic rash that begins on the abdomen, spreads to the
face and proximal extremities, and can result in grave
complications?
1. Rubella
120.
2. Rubeola
3. Chickenpox
4. Scarlet fever
The parent of a child who has received all of the primary
immunizations asks the nurse which ones the child should
receive before starting kindergarten. The nurse tells the
parent that her child should receive boosters of:
1. IPV, HepB, Td.
2. DTaP, HepB, Td.
3. MMR, DTaP, Hib.
4. DTaP, IPV, MMR.
121. A nurse is reviewing the immunization schedule of an
11-month-old infant. What immunizations does the nurse
expect the infant to have previously received?
1. Pertussis, tetanus, polio, and measles
2. Diphtheria, pertussis, tetanus, and polio
3. Rubella, polio, tuberculosis, and pertussis
4. Measles, mumps, rubella, and tuberculosis
122. During a vaccination drive at a well-child clinic, a nurse
observes that a recently hired nurse is not wearing
gloves. What should the nurse advise the newly hired nurse
to do?
1. Speak with the nurse manager regarding techniques.
2. Put on gloves because standard precautions are required.
3. Continue with the immunizations because gloves are not
needed.
4. Evaluate the child’s appearance to determine whether
gloves are needed.
123. A 12-month-old infant has become immunosuppressed
during a course of chemotherapy. When preparing the
parents for the infant’s discharge, what information should
the nurse give concerning the measles, mumps, and rubella
(MMR) immunization?
1. It should not be given until the infant reaches 2 years of
age.

2. Infants who are receiving chemotherapy should not be
given these vaccines.
3. It should be given to protect the infant from contracting
any of these diseases.
4. The parents should discuss this with their health care
provider at the next visit.
124. A parent and 4-year-old child who recently emigrated from
Colombia arrive at the pediatric clinic. The child has a
temperature of 102° F, is irritable, and has a runny nose.
Inspection reveals a rash and several small, red, irregularly
shaped spots with blue-white centers in the mouth. What
illness does the nurse suspect the child has?
1. Measles
2. Chickenpox
3. Fifth disease
4. Scarlet fever
Nursing Care of Toddlers
rs
125. A health care provider prescribes amoxicillin 145 mg by
u mouth three times daily for a 28-lb toddler. It is supplied
as a suspension of 250 mg/5 mL. The safe dosage is
decimal place.
Answer: __________ mg
nu
35 mg/kg/24 hours. How many milligrams within the safe
dosage limit is the dose? Record your answer using one
l_
126. A parent calls the outpatient clinic requesting information
about the appropriate dose of acetaminophen for a
16-month-old child who has signs of an upper respiratory
tract infection and fever. The directions on the bottle of
ca
acetaminophen elixir are 120 mg every 4 hours when
needed. At the toddler’s 15-month visit, the health care
provider prescribed 150 mg. What is the nurse’s best
response to the parent?
i
1. “The dose is close enough, and it doesn’t really matter
in
which one is given.”
2. “From your description, the medications are not neces-
sary. They should be avoided at this age.”
3. “It is appropriate to use dosages based on age. Child
cl
­
ren typically have weights consistent for their age
groups.”
4. “The prescribed dose of the drug was based on weight,
@
and this is a more accurate way of determining a thera-
peutic dose.”
127. A nurse in the emergency department observes large welts
and scars on the back of a child who has been admitted for
an asthma attack. What additional information must be
included in the nurse’s assessment?
1. History of an injury
2. Signs of child abuse
3. Presence of food allergies
4. Recent recovery from chickenpox
128. The parents of a 2-year-old child tell the nurse that they are
having difficulty disciplining their child. What is the nurse’s
most appropriate response?
1. “This is a difficult age that your child is going through
right now.”
Review Questions 719
2. “Tell me more about your difficulty. I’m not sure what
you mean by this.”
3. “It’s important to be consistent with toddlers when
they need disciplining.”
4. “I can understand what you mean. That’s why this age is
called the terrible twos.”
129. A 13-year-old girl tells the nurse at the pediatric clinic that
she took a pregnancy test and it was positive. She adds that
her grandfather, with whom she, her younger sisters, and
her mother live, has repeatedly molested her for the past 3
years. When the nurse asks the girl if she has told this to
anyone, she replies, “Yes, but my mother doesn’t believe me.”
Legally, who should the nurse notify?
1. Police concerning a possible sex crime
g
2. Health care provider to confirm the pregnancy
3. Child Protective Services for immediate intervention
in
4. Girl’s mother about the pregnancy test’s positive result
130. Where should the nurse manager place a 5-year-old child
admitted with injuries that may be related to abuse?
1. In a private room
2. With an older, friendly child
3. With a child of the same age
4. In a room near the nurses’ desk
131. What is one of the most important factors that a nurse must
consider when parents of a toddler request to be present at
a procedure occurring on the hospital unit?
1. Type of procedure to be performed
2. Individual assessment of the parents
3. Whether the toddler wants the parents present
4. Probable reaction to the toddler’s response to pain
132. At 2 years of age, a child is readmitted to the hospital for
additional surgery. What is the most important factor in
preparing the toddler for this experience?
1. Gratification of the child’s wishes
2. Previous experience of being hospitalized
3. Avoidance of leaving the child with strangers
4. Assurance of continuation of parental affection
133. On the third day of hospitalization the nurse observes that
a 2-year-old toddler who had been screaming and crying
inconsolably begins to regress and is now lying quietly in
the crib with a blanket. What stage of separation anxiety has
developed?
1. Denial
2. Despair
3. Mistrust
4. Rejection
134. What behavior does a nurse expect from a toddler subjected
to prolonged hospitalization with limited parental visits?
1. Cheerful interactions with staff members
2. Indications of sadness throughout the day
3. Excessive crying when parents are not present
4. Limited emotional response to the environment
135. During the second week of hospitalization for intravenous
antibiotic therapy, a 2-year-old toddler whose family is
unable to visit often smiles easily, goes to all the nurses
happily, and does not express interest in the parent when
the parent does visit. The parent tells the nurse, “I am
pleased about the adjustment but somewhat concerned
720 CHAPTER 35 Child Health Nursing

about my child’s reaction to me.” How should the nurse
respond?
1. The child is repressing feelings for the parent.
2. Routines have been established and the child feels safe.
3. The child has given up fighting and accepts the
separation.
4. Behavior has improved because the child feels better
physically.
136. The nurse accompanies a 3-year-old child to the playroom.
u The toddler seems afraid to select a toy or activity. What
age-appropriate play material should the nurse offer? Select
all that apply.
1. Plastic tea set
2. Mold and clay
1. “Toddlers need discipline to prevent the development of
antisocial behaviors.”
2. “Toddlers are learning to assert independence, and this
behavior is expected at this age.”
3. “It is best to leave the toddler alone in the crib after
calmly explaining why the behavior is unacceptable.”
4. “This is the way a toddler expresses needs, and this
behavior is acceptable during the initiative stage of
development.”
142. A parent tells a nurse at the clinic, “Each morning I offer
my 24-month-old child juice, and all I hear is ‘No.’ What
should I do because I know my child needs fluid?” What
strategy should the nurse suggest?
1. Offer the child a choice of two juices.

g
3. Play telephone 2. Distract the child with a favorite food.
4. Pencil and paper 3. Offer the child the glass in a firm manner.

in
5. Simple video game 4. Allow the child to see the parent getting angry.
137. When teaching a group of parents in the daycare center 143. A 2-year-old child who was admitted to the hospital for
about accident prevention, the nurse explains that young further surgical repair of a clubfoot is standing in the crib,

rs
toddlers are prone to injuries from falls. When receiving
feedback, the nurse identifies that more teaching is needed
when one parent states, “I will:
1. keep medications in a medicine cabinet.”
crying. The child refuses to be comforted and calls for the
mother. As the nurse approaches the crib to provide morning
care, the child screams louder. Knowing that this behavior
is typical of the stage of protest, what is the most appropriate

138.
u
2. have secured gates at entrances to staircases.”

nu
3. move our child to a regular bed by the age of 2 1 2.”
4. buy shoes that close with Velcro rather than laces.”
A 2 1 2-year-old child is admitted to the hospital with deep
nursing intervention?
1. Use comforting measures while holding the child.
2. Fill the basin with water and proceed to bathe the child.
3. Sit by the crib and bathe the child later when the anxiety
l_
partial thickness burns involving the face and chest. The decreases.
nurse develops a plan of care based on concerns related to 4. Postpone the bath for a day because a child this upset
the child’s injury. Place the following in order of should not be traumatized further.
importance. 144. A major developmental milestone of a toddler is the achieve-
ca

1. _____ Presence of pain ment of autonomy. What should the nurse instruct the
2. _____ Potential for infection parents to do to enhance their toddler’s need for
3. _____ Impaired gas exchange autonomy?
4. _____ Disturbed fluid balance 1. Teach the child to share with others.
i

5. _____ Compromised body image 2. Help the child to learn society’s roles.
in

139. A 3-year-old child ingests a substance that may be a poison. 3. Teach the child to accept external limits.
The parent calls a neighbor who is a nurse and asks what 4. Help the child to develop internal controls.
to do. What should the nurse recommend the parent 145. The nurse observes a 2-year-old child at play and identifies
to do? u that the child is engaging in age-appropriate behavior for a
cl

1. Administer syrup of ipecac. toddler. Which activities lead the nurse to this conclusion?
2. Call the poison control center. Select all that apply.
3. Take the child to the emergency department. 1. Is possessive of toys
@

4. Give the child bread dipped in milk to absorb the
poison.
140. A nurse in the child life center is evaluating a 15-month-old
u toddler’s ability to perform physical tasks. What behavior
indicates to the nurse that the child’s development is age
appropriate? Select all that apply.
1. Shares toys.
2. Drinks from a cup.
3. Builds a tower of six blocks.
4. Walks with a wide-based gait.
5. Throws toys around the room.
141. A parent brings an 18-month-old toddler to the clinic. The
parent states, “My child is so difficult to please, has temper
tantrums, and annoys me by throwing food from the table.”
What is the nurse’s best response?
2. Follows simple directions
3. Can play simple card games
4. Enjoys playing with other children
5. Attempts to stay within the lines when coloring
146. After the nurse has completed an oral examination of a
healthy 2-year-old child, the parent asks when the child
should first be taken to the dentist. When is the most
appropriate time in the child’s life for the nurse to suggest?
1. Before starting school
2. Within the next few months
3. When the first deciduous teeth are lost
4. At the next time a family member visits the dentist
147. The nurse explains to the parent of a 2-year-old child that
the toddler’s negativism is expected at this age. What need
is this behavior meeting?
 Review Questions 721

1. Trust 3. Expected behavior in a toddler of this age

2. Attention
3. Discipline
4. Independence
148. The parent of a 2-year-old child tells a nurse at the clinic,
“Whenever I go to the store, my child has a screaming
tantrum, demanding a toy or candy on the shelves. How
can I deal with this situation?” What is the nurse’s best
response?
1. “Attempt to distract the child by offering the child a toy”
2. “Say nothing and allow the tantrum to continue until it
ends.”
3. “Have a baby sitter stay with the child at home until the
child outgrows this behavior.”
4. Existence of developmental dysplasia of the hip
155. What toys should a nurse offer a young toddler during
u hospitalization? Select all that apply.
1. Mobile
2. Tricycle
3. Pounding toy
4. Carton of clay
5. Ten-piece puzzle
156. A parent tearfully tells a nurse, “They think our child is
developmentally delayed. We are thinking about investigat-
ing a preschool program for cognitively impaired children.”
What is the nurse’s most appropriate response?
1. Praise the parent for the decision and encourage the plan.

g
4. “Give the child the item while in the store, and when the 2. Ask for more specific information related to the develop-
child loses interest, return the item to the shelf.” mental delays.

in
149. What foods should a nurse order for a 30-month-old toddler 3. Advise the parent to have the health care provider help
on a regular diet? choose an appropriate program.
1. Hamburger with bun and grapes 4. Explain that this may be a premature action and the

rs
2. Chicken fingers and french fries developmental delays could disappear.
3. Hot dog with bun and potato chips 157. A nurse on the pediatric unit is observing the developmental
4. Macaroni and cheese and Cheerios skills of several 2-year-old children in the playroom. Which
150. During a nap, a 3-year-old hospitalized child wets the bed. child should the nurse continue to evaluate?
How should the nurse respond?
1. Ask the child to help with remaking the bed.
nu
2. Put clean sheets on the bed over a rubber sheet.
3. Change the child’s clothes without discussing the
1. Cannot stand on 1 foot
2. Builds a tower of 7 blocks
3. Uses echolalia when speaking
4. Colors outside the lines of a picture
l_
incident. 158. A nurse plans to talk to the parents of a toddler about toilet
4. Explain that children should call the nurse when they training. What should the nurse explain is the most impor-
need to go to the bathroom. tant factor in the process of toilet training?
151. A nurse is evaluating a 3-year-old child’s developmental 1. Parents’ attitude about it
ca

progress. The inability to perform which task indicates to 2. Child’s desire to remain dry
the nurse that there is a developmental delay? 3. Child’s ability to sit still on the toilet
1. Copying a square 4. Parents’ willingness to work at the toilet training
2. Hopping on one foot 159. A parent asks the nurse what to do when their toddler has
i

3. Catching a ball reliably temper tantrums. What play materials should the nurse
in

4. Using a spoon effectively suggest to offer the child as another way of expressing anger?
152. Which healthy snack should the nurse teach the parents to 1. Ball and bat
u give their 2-year-old child who has the diagnosis of acute 2. Wad of clay
asthma? Select all that apply. 3. Punching bag
cl

1. Grapes 4. Pegs and pounding board

2. Ice cream 160. When the working mother of a toddler is preparing to take
3. Apple slices her child home after a prolonged hospitalization, she asks
@

4. Oatmeal cookies the nurse what type of behavior she should expect to be
5. Cut up vegetables displayed. What is the nurse’s most appropriate description
6. Cold glass of milk of her child’s probable behavior?
153. What type of play does a nurse expect when observing a 1. Excessively demanding behavior
toddler in a playroom with other children? 2. Hostile attitude toward the mother
1. Parallel 3. Cheerful, with shallow attachment behaviors
2. Solitary 4. Withdrawn, without emotional ties to the mother
3. Cooperative 161. A 15-month-old child with the diagnosis of hydrocephalus
4. Competitive is to have a computed tomography (CT) scan. What should
154. While assessing an 18-month-old child, a nurse observes the nurse include when preparing the toddler for the CT
that the toddler can crawl upstairs but needs assistance when scan?
climbing the stairs upright. What does this action indicate 1. Shaving the head
to the nurse? 2. Starting the prescribed IV infusion
1. Presence of talipes equinovarus 3. Administering the prescribed sedative
2. Reflective of neurologic damage 4. Giving the child a simple explanation of the procedure
722 CHAPTER 35 Child Health Nursing
162. An 8-year-old child with cerebral palsy is admitted to the
hospital for a tendon-lengthening procedure. After the
surgery, the parents ask a nurse why their child must wear
braces and shoes for at least 12 hours a day even while in
bed. How should the nurse respond?
1. “Ambulation can be encouraged as soon as possible.”
2. “They maintain body alignment and help prevent
footdrop.”
3. “They stretch your child’s ligaments and strengthen
muscle tone.”
4. “It helps your child accept the physical constraints of
the condition.”
163. What safety precautions should a nurse teach a child with
diminished sensation in the legs because of cerebral palsy?
1. Test the temperature of the water before a bath.
2. Tighten brace straps securely before ambulating.
3. Set the clock twice during the night to change
position.
4. Look down at the legs when crutch walking to determine
rs
how they are positioned.
164. When planning long-term care for a child with cerebral
palsy (CP), it is important for the nurse to consider that the:
1. illness is not progressively degenerative.
2. effects of cerebral palsy are unpredictable.
nu
3. child probably has some degree of mental retardation.
4. child should have genetic counseling before planning a
family.
l_
165. A school nurse is teaching a group of teachers’ aides about
the cause of lead poisoning in children. What is important
to consider in terms of prevention?
1. It is known to be caused by the ingestion of foods that
ca
are high in fat.
2. It is attributed to an indigent and passive parent who fails
to supervise the children.
3. Environmental factors are involved because lead is avail-
i
able for ingestion and inhalation.
in
4. Socioeconomic factors are involved, because inadequately
maintained old buildings have more lead-based paint.
166. A nurse is assessing a child with plumbism (lead poisoning).
Which organ system is of most concern because of its irre-
cl
versible side effects?
1. Urinary
2. Skeletal
@
3. Nervous
4. Hematologic
167. A nurse is assessing a child with the diagnosis of lead poison-
ing. What is the most harmful adverse effect that the nurse
anticipates?
1. Inadequate nutrition
2. Delayed development
3. Anemia and constipation
4. Renal and skeletal damage
168. If a child cannot be given or is not responding to oral chelat-
ing agents, parenteral medication must be used. To effec-
tively prepare a child to cope with this painful treatment,
what is the priority nursing intervention?
1. Rotating the injection sites and adding procaine to the
chelating agent to lessen the discomfort
2. Role-playing with puppets dressed as hospital personnel
to minimize the child’s fear of unfamiliar adults
3. Explaining the rationale for the injections so that the
child does not view them as a punishment for bad
behavior
4. Therapeutic play using a needleless syringe and a doll
before therapy is initiated and after receiving each
injection
169. A nurse encourages parents to have their young children’s
eyes tested especially for monocular strabismus. What
should the nurse explain can occur if it is not corrected early?
1. Dyslexia will develop.
2. Peripheral vision will disappear.
3. Vision in both eyes will be diminished.
g
4. Amblyopia will progress in the weak eye.
170. A nurse is teaching the parents of a 2-year-old child the
in
correct way to administer ear drops. After explaining that
they position their child on the side, how should they move
the pinna while instilling the drops?
1. Forward
2. Up and back
3. Straight back
4. Down and back
171. A nurse talks with parents of a toddler with strabismus about
why this condition should be treated in early childhood.
What complication should the nurse explain can occur if it
is not corrected?
1. Cataracts
2. Glaucoma
3. Refractive errors
4. Partial loss of sight
172. The nurse observes that a 6-month-old infant is startled by
a loud noise but does not turn in the direction of the sound.
How should the nurse interpret this response?
1. Effect of vision deficits
2. Evidence of hearing loss
3. Low-normal hearing range
4. Developmentally appropriate
173. After many episodes of otitis media, a 3-year-old child is to
have a myringotomy with tubes implanted surgically. What
should the nurse include in the discharge preparation for
this family?
1. Keep the child at home for one week.
2. Insert earplugs during the child’s bath.
3. Apply an ointment to the ear canal daily.
4. Use cotton swabs to clean the inner ears.
174. During a well-child visit the parents tell a nurse, “Our
3-year-old child does not listen to us when we speak and
ignores us.” After an auditory screening, it is determined
that the child has a mild hearing loss. What should the nurse
explain to the parents about a mild hearing loss?
1. A severe hearing deficit may develop.
2. It will not interfere with progress in school.
3. An immediate follow-up visit is not necessary.
4. Speech therapy in addition to hearing aids may be
required.
175. A child sustains multiple fractures from a motor vehicle
u collision and casts are applied. The child is admitted for

observation to rule out internal injuries. The health care
provider orders vital signs, including blood pressures, every
4 hours. The nurse decides to use the posterior tibial artery
to obtain the blood pressure. Place a line across the extremity
where the blood pressure cuff should be positioned to obtain
this blood pressure.
rs
nu
l_
176. A young child with a leg fracture of suspicious origin is
brought into the emergency department by the mother and
the mother’s boyfriend. It is the child’s first visit to this
ca
hospital. After assessing the child, a nurse anticipates that
the health care provider will order a skeletal survey. Why is
a skeletal survey the preferred diagnostic tool?
1. The exact location and extent of the fracture will be
i
pinpointed.
in
2. It is the first step toward a complete assessment before a
CT scan and an MRI are done.
3. Three separate x-ray films of the leg and hip should be
ordered, making it more cost effective.
cl
4. The skeletal history of the current fracture and any previ-
ous healing or healed fractures are identified.
177. A 9-year-old child has a fractured tibia, and a full leg cast is
@
u applied. Which assessments should the nurse immediately
report to the health care provider? Select all that apply.
1. Increased urinary output
2. Inability to move the toes
3. Pedal pulse of 90 beats/min
4. Tingling sensation in the foot
5. Fiberglass cast that is damp after 4 hours
178. An infant has a plaster cast applied for clubfoot correction.
What nursing intervention will hasten drying of the cast?
1. Using a blow dryer
2. Opening the window
3. Exposing the casted extremity
4. Covering the cast with a light sheet
179. A child just had a cast applied for a fractured wrist. The wrist
u and elbow are immobilized. What information should the
Review Questions 723
nurse include in the home care instructions before discharge?
Select all that apply.
1. Resume usual activities.
2. Report swelling of fingers.
3. Elevate casted arm when standing.
4. Keep affected shoulder immobilized.
5. Lower the casted arm when lying down.
180. A 3-year-old child is admitted with partial- and full-thickness
burns over 30% of the body. What significant adverse
outcome during the first 48 hours should the nurse attempt
to prevent?
1. Shock
2. Pneumonia
3. Contractures
g
4. Hypertension
181. A 6-year-old child has partial-thickness burns of the face and
in
upper chest. What is the priority nursing assessment for the
first 24 hours?
1. Wound sepsis
2. Pulmonary distress
3. Fear and separation anxiety
4. Fluid and electrolyte imbalance
182. A 15-year-old adolescent is admitted with partial- and full-
u thickness burns of the arms and upper torso. What are the
purposes of administering pain medication via the intrave-
nous route rather than the intramuscular route? Select all
that apply.
1. Adolescents are afraid of injections.
2. It decreases the risk for tissue irritation.
3. Severe pain is reduced more effectively.
4. Impaired peripheral circulation is bypassed.
5. It provides for more prolonged relief of pain.
183. What should the nurse teach parents is the major influence
on the eating habits of early school-age children?
1. Smell and appearance of food
2. Availability of food selections
3. Food preferences of the peer group
4. Example of parents and siblings at mealtimes
184. A child receives a gastrostomy tube feeding every 4 hours.
What is the priority nursing intervention for this child?
1. Open the tube one hour before feeding.
2. Keep the child lying flat during the feeding.
3. Flush the tube with normal saline after feeding.
4. Position the child on the right side after feeding.
185. An unconscious child requires intermittent nasogastric
feedings. When should the nurse check placement of the
tube?
1. Once a day
2. Before each feeding
3. At every shift change
4. During the night shift
186. A nurse is obtaining a health history from the parents of a
child with celiac disease. What characteristic does the nurse
expect when the parents describe their child’s stools?
1. Small, pale, mucoid
2. Large, frothy, green
3. Large, pale, foul-smelling
4. Moderate, green, foul-smelling
724 CHAPTER 35 Child Health Nursing

187. The parents of a 6-year-old child with celiac disease tell the
school nurse that their child becomes dejected because of
not being able to eat “snack” food like the rest of the chil-
dren. What snack can the nurse recommend that is safe for
the child to eat?
1. Pretzels 195.
2. Tortilla chips
3. Oatmeal cookies
4. Peanut butter crackers
188. The parents of a child newly diagnosed with cystic fibrosis
tell a nurse that even though they were told it is an inherited
disorder there is no history of cystic fibrosis in the family. 196.
How can the nurse clarify the way it was inherited?
1. It is a mutated gene.
bag of 0.45% sodium chloride. It is to be infused over 30
minutes. At what rate should the infusion pump be set to
deliver the medication in the prescribed time? Record your
answer using a whole number.
Answer: __________ mL/hour
What is an important nursing intervention during the care
of a hospitalized child with cystic fibrosis?
1. Discourage coughing.
2. Perform postural drainage.
3. Encourage active exercise.
4. Provide small, frequent feedings.
When is the most appropriate time for the nurse to plan for
chest percussion and postural drainage for a toddler with
cystic fibrosis?

g
2. It involves an X-linked gene. 1. After suctioning
3. The inheritance is autosomal recessive. 2. Before aerosol therapy

in
4. The inheritance is autosomal dominant. 3. One hour before meals
189. The parents of a child newly diagnosed with cystic fibrosis 4. Fifteen minutes after meals
ask a nurse what causes the problems related to this disorder. 197. A child with cystic fibrosis has recurrent episodes of bron-

rs
What should the nurse consider about the primary pathol- chitis and the parents ask the nurse why this happens. What
ogy before responding? reason should the nurse include in the reply?
1. Hyperactivity of the eccrine (sweat) glands 1. Associated heart defects cause heart failure and respira-
2. Hypoactivity of the autonomic nervous system tory depression.
3. Mechanical obstruction of mucus-secreting glands
4. Atrophic changes in the mucosal lining of the
intestines nu
190. The parents of a child newly diagnosed with cystic fibrosis
2. Neuromuscular irritability causes spasm and constric-
tion of the bronchi.
3. Tenacious secretions that obstruct the respiratory tract
provide a favorable medium for growth of bacteria.
l_
ask a nurse what causes the foul-smelling, frothy stool. What 4. Elevated salt content in saliva irritates the mucous mem-
should be included in the nurse’s answer? branes, resulting in inflammation of the nasopharynx.
1. Undigested fat 198. What should a nurse teach the parents of a toddler newly
2. Sodium and chloride diagnosed with cystic fibrosis about the administration of
ca

3. Lipase, trypsin, and amylase vitamins A, D, E, and K?

4. Partially digested carbohydrates 1. Offer them in a water-miscible form.
191. A child with cystic fibrosis has been hospitalized with bacte- 2. Give them during meals and snack time.
rial pneumonia. The nurse determines that the child has 3. Calibrate them based on height and weight.
i

no known allergies. What does the nurse conclude about 4. Present them with fruit juice rather than milk.
in

the reason the health care provider selected a specific 199. Which medications does the nurse expect to be prescribed
antibiotic? u for a child newly diagnosed with cystic fibrosis? Select all
1. Tolerance of the child that apply.
2. Sensitivity of the bacteria 1. Steroids
cl

3. Selectivity of the bacteria 2. Antibiotics

4. Preference of the health care provider 3. Antihistamines
192. A nurse is assessing a school-age child with cystic fibrosis. 4. Pancreatic enzymes
@

What complication of frequent stools and tenacious mucus 5. Fat-soluble vitamins

does the nurse anticipate?
1. Anal fissures
2. Rectal prolapse
3. Intussusception
4. Meconium ileus
193. A nurse teaches a 5-year-old child with cystic fibrosis how
to use an inhaler. What is the most appropriate way to
evaluate understanding of the technique?
1. Asking questions about using the inhaler
2. Showing the nurse how to use the inhaler
3. Explaining how the inhaler will be used at home
4. Telling the nurse about the technique that was learned
194. A 7-year-old child with cystic fibrosis is receiving an intra-
u venous antibiotic. The medication is supplied in a 125-mL
200. A nurse can assist in confirming a suspected diagnosis of
intestinal infestation with pinworms in a 6-year-old child
by:
1. teaching the mother the procedure for an anal cellophane-
tape test.
2. asking the mother to collect stools for 3 consecutive days
for culture.
3. having the mother bring in the child’s stools for visual
examination for 3 days.
4. assisting the mother to schedule a hypersensitivity test of
the child’s blood serum.
201. A nurse teaches a parent how to perform a cellophane-tape
test for pinworms. At what time should the nurse teach the
parent to perform the test?
 Review Questions 725

1. Immediately after meals and vitamin B12. What other nutrient should the nurse
2. Following a bowel movement include?
3. At bedtime before the child’s bath 1. Calcium
4. Early morning before the child gets up 2. Thiamine
202. Pinworms cause a number of symptoms besides anal itching. 3. Folic acid
A complication of pinworm infestation, although rare, that 4. Riboflavin
the nurse should be aware of is: 210. A nurse is developing a teaching plan for a child who has
1. hepatitis. u anemia related to inadequate nutrition. In addition to iron,
2. stomatitis. which nutrients should the nurse include that are necessary
3. pneumonitis. for RBC synthesis? Select all that apply.
4. appendicitis. 1. Protein
203. Mebendazole (Vermox) is prescribed for a child with pin- 2. Calcium
worms. For whom should this medication also be 3. Vitamin C
prescribed? 4. Vitamin D

g
1. The child’s infant brother 5. Carbohydrates
2. People using the same toilet facilities as the child 211. A pale, lethargic 1-year-old infant weighs 12.6 kg (28 lb)

in
3. Members of the child’s family after they test positive and has a hemoglobin level of 9 g/dL. The parent tells the
4. The child’s immediate family members even if they are nurse that the infant refuses solid food when it is offered by
symptom-free spoon and drinks between four and six full bottles of milk

rs
204. The health care provider prescribes mebendazole (Vermox) per day. What should the nurse recommend?
for a 4-year-old child with pinworms. What should the 1. Begin the weaning process immediately.
nurse prepare the parents to expect when they observe the 2. Take the infant to the metabolic clinic for an
child’s stool? examination.
1. Blood
2. Constipation
3. Yellow color
4. Passage of worms
nu 3. Give the infant finger foods such as dry cereal and
chopped meat.
4. Puncture a large hole in the nipple and add puréed baby
foods to the milk.
l_
205. A nurse working at a summer camp is informed of an out- 212. A nurse is performing health screening of toddlers in a
break of scabies. For what clinical indicator should the nurse culturally diverse neighborhood. Which child should the
screen the children? nurse consider at risk for β-thalassemia (Cooley anemia)?
1. Pruritic, threadlike lesions in skin folds 1. Two-year-old child of Greek descent with a large
ca

2. Grayish white particles adhering to hair shafts abdomen

3. Central necrotic ulcer surrounded by petechiae 2. Eighteen-month-old child of Irish descent with very pale
4. Reddened, round areas of alopecia over the scalp skin color
206. The parent of a 14-month-old toddler asks the nurse about 3. Three-year-old child of Spanish descent with an increased
i

how to proceed with bowel training. What should the nurse hematocrit
in

recommend to optimize success? 4. Twenty-month-old child of Asian descent with edema-

1. Place the child on the toilet every 2 hours. tous knee joints
2. Start by having the child sit on a potty chair. 213. A child with β-thalassemia (Cooley anemia) is admitted to
3. Avoid bowel training until the child is 2 years old. the ambulatory care unit for a transfusion. What instruc-
cl

4. Begin before the child’s diet consists mainly of solid tions should the nurse include in the discharge plan?
foods. 1. Encourage fluids.
207. A nurse is planning for the discharge of a child after a sickle 2. Restrict activities.
@

cell vaso-occlusive crisis (pain episode). What is most
important for the nurse to emphasize?
1. A high-calorie diet
2. A rigorous exercise regimen
3. An increased intake of fluids
4. An increase in the hours spent sleeping
208. A child is to receive a blood transfusion. What should the
nurse do first if an allergic reaction to the blood occurs?
1. Shut off the infusion.
2. Slow the rate of flow.
3. Administer an antihistamine.
4. Call the health care provider.
209. When counseling the parents of a child with anemia related
to an inadequate diet, a nurse explains that several different
nutrients are involved. These nutrients include protein, iron,
3. Protect from infections.
4. Offer small meals frequently.
214. A child with sickle cell disease has a sequestration crisis. The
parents ask how it differs from a painful episode (vaso-
occlusive crisis). What should the nurse consider before
responding?
1. There is peripheral ischemia along with the pain.
2. There is decreased blood volume and signs of shock.
3. Red blood cell production diminishes with severe anemia.
4. Red blood cell destruction is accelerated and jaundice
appears.
215. A nurse is caring for a child with sickle cell anemia. What
is the priority nursing intervention to prevent thrombus
formation in capillaries and the stasis and clotting of blood
that occur in the sickling process?
726 CHAPTER 35 Child Health Nursing

1. Encourage fluids. 4. Be unable to relate to children in the playroom if other

2. Encourage bed rest. parents are present
3. Administer oxygen. 222. A 4-year-old child is diagnosed with acute lymphoblastic
4. Administer prescribed anticoagulants. leukemia (ALL). One of the parents tells the nurse, “We just
216. A child is admitted to the pediatric unit with a hemoglobin had a discussion with our pediatrician about induction che-
level of 6.4 g/dL. What should be the nurse’s priority motherapy, consolidation therapy, and radiation therapy.
assessment? We are so confused and don’t know what to do. We want
1. Manifestations of shock to do what is best for our child, but we don’t want any
2. Increased white cell count unnecessary suffering.” What is the nurse’s best response?
3. Presence of hemoglobinuria 1. “The new treatment protocols have shown to have excel-
4. Signs of cardiac decompensation lent results.”
217. A child in sickle cell crisis (painful episode) reports right 2. “There are support groups for parents with children who
knee pain. What should the nurse anticipate the health care have leukemia.”
provider will order? 3. “Let me get you the telephone number of the Leukemia

g
1. Wrap the knee in a cold pack. Society, where you can get some advice.”
2. Apply a warm soak to the knee. 4. “Maybe you could talk with your health care provider

in
3. Administer 0.5 mg of morphine. about getting a second opinion from a specialist in
4. Decrease the amount of IV fluids. leukemia.”
218. What nursing care to prevent a crisis is the same for children 223. A child with nephrotic syndrome has repeated relapses. As

rs
with sickle cell anemia and celiac disease? the child gets older, what is most important for the nurse
1. Limit activity. to help the child develop?
2. Protect from infection. 1. A positive body image
3. Document color and consistency of stools. 2. The ability to test urine

219.
u nu
4. Offer a low-carbohydrate, high-protein, low-fat diet.
A 6-year-old child with sickle cell disease is admitted with
a vaso-occlusive crisis (painful episode). What are the prior-
ity nursing concerns? Select all that apply.
224.
3. Fine muscle coordination
4. Acceptance of possible sterility
A 4-year-old child with nephrotic syndrome is being treated
with corticosteroid therapy. A nurse reviews the laboratory
l_
1. Nutrition reports of the child’s urine to evaluate if the treatment has
2. Hydration been effective. Which of the following should decrease?
3. Pain management 1. Polyuria
4. Prevention of infection 2. Hematuria
ca

5. Oxygen supplementation 3. Glycosuria

4. Proteinuria
225. A 4-year-old child being admitted for surgery arrives on the
ambulatory surgical unit crying and pulling at the hospital
i

Nursing Care of Preschoolers gown while clutching a teddy bear. What is the nurse’s best
in

220. A 4-year-old child is brought to the emergency department
after falling on the handlebars of a tricycle. The child is
guarding the abdomen, crying, and not allowing any physi-
cl
response?
1. “Please stop crying. Nobody will hurt you.”
2. “Hello, I’m your nurse. Let’s go and see your room.”
3. “I know you feel scared. This must be your special teddy

cal contact with the staff. Which action best enables the bear.”
nurse to initiate the assessment process? 4. “We want you to be happy here. Let’s go to the playroom
1. Medicate the child for pain before proceeding. and play.”
@

2. Allow the child to guide the examiner’s hand to the area
that hurts.
3. Have the parents restrain the child while the abdomen is
auscultated.
4. Suggest the health care provider order a computed
tomography of the child’s abdomen.
221. The parents of a 4 1 2-year-old child are concerned about the
effects of hospitalization on their child. Which behavior
should the nurse expect the child to exhibit?
1. Refuse to cooperate with the nurses when the parents are
absent
2. Demonstrate despair if the parents do not visit at least
once a day
3. Cry when the parents leave and return but not during
their absence
226. A nurse is caring for a preschooler who is being prepared for
surgery. What does the nurse expect to have the most influ-
ence on the child’s response to hospitalization?
1. Fear of separation
2. Fear of bodily harm
3. Belief in death’s finality
4. Belief in the supernatural
227. What is a nurse’s best approach when preparing a 4-year-old
child for an otoscopic examination?
1. “This tube will feel like a pencil in your ear.”
2. “You can help by holding this tube while I get ready.”
3. “Please try to sit very still while I’m looking through the
tube.”
4. “It won’t hurt a bit when I look into your ear through
this tube.”

228. When a nurse brings a dinner tray to a 4-year-old child
hospitalized with pneumonia, the child says, “I’m too sick
to feed myself.” How should the nurse respond?
1. “Try to eat as much as you can.”
2. “You can eat later when you feel better.”
3. “Wait a few minutes, and I will be back to help you.”
4. “You’re really not that sick, and I’m sure you can feed
yourself.”
229. What is the best way for a nurse to meet a 3-year-old child
sitting in the waiting room of the pediatric clinic?
1. Walk into the waiting room to greet the child.
2. Call the child by name at the waiting room door.
3. Ask the receptionist to bring the child into the examining
room.
4. Stand at the examining room door while the child walks
down the hall.
230. A child recovering from a severe asthma attack is given
predniSONE 15 mg po twice daily. What is the priority
nursing intervention?
rs
1. Prevent exposing the child to infection.
2. Have the child rest as much as possible.
3. Check the child’s eosinophil count daily.
4. Offer nothing by mouth to the child except oral
medications.
nu
231. A child with acute lymphoid leukemia (ALL) is started on
chemotherapy protocol that includes predniSONE. What
side effect of this medication does the nurse anticipate?
l_
1. Alopecia
2. Anorexia
3. Weight loss
4. Mood changes
ca
232. A nurse is caring for a child with acute lymphoid leuke-
mia who is receiving chemotherapy. The parents ask why
the child needs predniSONE. How should the nurse
respond?
i
1. It decreases inflammation.
in
2. Production of lymphocytes is suppressed.
3. It increases appetite and a sense of well-being.
4. Irradiation skin irritation and edema are reduced.
233. A prescription for predniSONE reads 10 mg four times per
cl
u day. The dose for children is 2 mg/kg/day. How many
pounds does the child weigh? Record your answer using a
whole number.
@
Answer: ______ pounds
234. A combination of drugs, including vinCRIStine and pred-
niSONE, is prescribed for a child with leukemia. For what
adverse effect should the nurse assess the child that indicates
vinCRIStine toxicity?
1. Hemolytic anemia
2. Irreversible alopecia
3. Gastrointestinal problems
4. Neurologic complications
235. A young child with acute nonlymphoid leukemia is admit-
ted to the pediatric unit with a fever and neutropenia. What
are the most appropriate nursing interventions to minimize
the complications associated with neutropenia?
1. Placing the child in a private room, restricting ill visitors,
and using strict handwashing techniques
Review Questions 727
2. Encouraging a well-balanced diet, including iron-rich
foods, and helping the child avoid overexertion
3. Avoiding rectal temperatures, limiting injections, and
applying direct pressure for five minutes after
venipuncture
4. Offering a moist, bland, soft diet; using toothettes rather
than a toothbrush; and providing frequent saline
mouthwashes
236. A nurse is teaching a class of nursing assistants about the
differences in providing care among various age groups.
Which age group of children does the nurse explain makes
the provision of nursing care the most challenging?
1. From 1 to 4 years of age
2. Between 6 and 8 years old
g
3. Between 6 and 12 months old
4. From birth to 6 months of age
in
237. A nurse in the child life center encourages preschool chil-
dren to engage in role-playing. The nurse considers this an
important part of socialization because it:
1. helps children think about careers.
2. teaches children about stereotypes.
3. encourages expression of concerns.
4. provides guidelines for adult behavior.
238. The nurse observes that a 4-year-old child is having difficulty
relating with some of the children in the playroom. What
does the nurse identify is the reason that this problem is not
unexpected with preschoolers?
1. At this age they engage only in parallel play.
2. At this age they are extremely dependent on their parents.
3. Fierce temper tantrums and negativism are typical
behaviors.
4. Exaggerating and boasting to impress others are typical
behaviors.
239. Parents express concerns to the nurse that their 4-year-old
child is spending a large amount of time playing with an
imaginary playmate. How should the nurse respond?
1. “Perhaps your child needs more interaction with friends.”
2. “You have reason to be concerned. This is not typical
behavior.”
3. “Imaginary playmates are an important part of a young
child’s life.”
4. “This is a sign of social immaturity. I recommend psy-
chological counseling.”
240. A nurse is caring for a preschooler on the pediatric unit. What
does the nurse identify as the child’s greatest fear at this age?
1. Death
2. Mutilation
3. Painful procedures
4. Isolation from peers
241. A nurse is attempting to involve a hospitalized preschooler
in therapeutic play. Why is this so important?
1. The child can work out ways of coping with fears.
2. It provides an opportunity to accept the hospital
situation.
3. The child can forget the reality of the situation for a
little while.
4. It provides an opportunity to meet other children on the
pediatric unit.
728 CHAPTER 35 Child Health Nursing

242. What nursing intervention is most effective in alleviating
the fretfulness of a hospitalized 5-year-old child?
1. Reading a story to the child
2. Giving a jigsaw puzzle to the child
3. Supplying the child with videos to watch
4. Offering the child crayons with drawing paper
243. A 5-year-old child is admitted to the pediatric intensive care
unit with a diagnosis of acute asthma. A blood sample is
obtained to measure the child’s arterial blood gases. What
finding does the nurse expect?
1. High oxygen level
2. Elevated alkalinity
3. Decreased bicarbonate
4. Increased carbon dioxide level
1. Offer ice chips on which to suck.
2. Encourage the intake of ice cream.
3. Keep the child in the supine position.
4. Gargle with a diluted mouthwash solution.
250. A 4-year-old child is diagnosed with mucocutaneous lymph
node syndrome (Kawasaki disease). The child is admitted to
the pediatric unit and the nurse performs an initial assess-
ment. What clinical finding supports this diagnosis?
1. Strawberry tongue
2. Copious discharges from the eyes
3. Insidious onset of low-grade fever
4. Maculopapular rash on the extremities
251. What is the most important nursing intervention for a
3-year-old child with a diagnosis of nephrotic syndrome?

g
244. When planning discharge teaching for the parents of a child 1. Regulating diet
with asthma, what information should the nurse include? 2. Encouraging fluids

in
1. Avoid foods high in fat. 3. Preventing infection
2. Stay at home for two weeks. 4. Maintaining bed rest
3. Increase the protein and calorie intake. 252. A child with nephrotic syndrome visits the clinic for a

rs
4. Minimize exertion and exposure to cold. follow-up visit. During the visit the parent states that the
245. When preparing a child with asthma for discharge, what child is always tired and has no appetite. The nurse observes
u must the nurse emphasize to the family? Select all that apply. that the child has a muddy, pale complexion. What problem
1. Eliminate allergens in the home. does the nurse suspect?
2. Maintain a dry home environment.
3. Avoid placing limits on the child’s behavior.
4. Continue the medications even if the child is
asymptomatic.
nu 1. Impending renal failure
2. Being too active in school
3. Developing a viral infection
4. Refusing the prescribed medications
l_
5. Prevent exposure to infection by having the child tutored 253. A health care provider lists orders for a young child with a
at home. tentative diagnosis of Wilms tumor. Which order should the
246. A child with a history of asthma is brought to the emergency nurse question?
u department experiencing an acute exacerbation of asthma. 1. MRI
ca

Which nursing assessments support this conclusion? Select 2. CT scan

all that apply. 3. Renal biopsy
1. Fever 4. Abdominal ultrasound
2. Crackles 254. A child who has been receiving prolonged steroid therapy
i

3. Wheezing u develops a cushingoid appearance. What will the nursing

in

4. Tachycardia assessment probably reveal? Select all that apply.

5. Hypotension 1. Truncal obesity
247. A child has been admitted to the pediatric unit with a severe 2. Thin extremities
asthma attack. What type of acid-base imbalance should the 3. Increased linear growth
cl

nurse expect the child to develop? 4. Loss of hair on the body

1. Metabolic alkalosis caused by excessive production of 5. Decreased blood pressure
acid metabolites 255. A 3-year-old preschooler has been hospitalized with
@

2. Respiratory alkalosis caused by accelerated respirations
and loss of carbon dioxide
3. Respiratory acidosis caused by impaired respirations and
increased formation of carbonic acid
4. Metabolic acidosis caused by the kidneys’ inability to
compensate for increased carbonic acid formation
248. After a tonsillectomy, which finding alerts the nurse to
suspect the initial stage of hemorrhage?
1. Noisy snoring
2. Asking for water
3. Frequent swallowing
4. Gradual onset of pallor
249. A child has a tonsillectomy and adenoidectomy for numer-
ous recurrent respiratory tract infections. Postoperatively
what should the nurse teach the parents to do?
nephrotic syndrome. What is the best way for the nurse to
evaluate fluid retention or loss?
1. Weigh daily at the same time.
2. Have the child urinate in a bedpan.
3. Measure the abdominal girth daily.
4. Test the child’s urine for proteinuria.
256. A nurse is caring for a child newly diagnosed with acute
u lymphoblastic leukemia (ALL). What clinical findings does
the nurse anticipate when assessing the child? Select all that
apply.
1. Pallor
2. Fatigue
3. Jaundice
4. Multiple bruises
5. Generalized edema
 Review Questions 729

257. A 4-year-old child newly diagnosed with leukemia is admit- the prescribed trimethoprim/sulfamethoxazole (Bactrim).
ted for chemotherapy. While assisting with morning care, Which common side effects should the nurse anticipate?
the nurse observes bloody expectorant after the child has Select all that apply.
brushed the teeth. How should the nurse respond to this 1. Jaundice
occurrence? 2. Vomiting
1. Secure a smaller toothbrush for the child to use. 3. Headache
2. Document the incident without alarming the child. 4. Toxic nephrosis
3. Tell the child to be more careful when brushing the 5. Hypersensitivity reactions
teeth. 264. A 10-year-old child is diagnosed with lymphocytic thyroid-
4. Rinse the child’s mouth with half-strength hydrogen itis (Hashimoto disease). What should the nurse explain to
peroxide. the parents and child about this condition?
258. A 3-year-old child who has acute lymphoblastic leukemia 1. It is chronic.
(ALL) is scheduled to receive cranial radiation. The nurse 2. Treatment is difficult.
should explain to the parents that radiation will: 3. It is an inherited disorder.

g
1. avoid the need for chemotherapy. 4. Regression occurs spontaneously.
2. reduce the risk for systemic infection. 265. A 7-year-old child is expressing fear concerning an uncom-

in
3. limit metastasis to the lymphatic system. fortable sterile dressing change. What should the nurse say
4. prevent central nervous system involvement. to be most therapeutic?
1. “Do you want some medicine so it won’t hurt?”

rs
2. “Will you help hold the package of bandages for
Nursing Care of School-Age Children me?”
3. “This won’t hurt if you try to relax while closing your
259. A 6-year-old child begins thumb-sucking after surgery. This eyes.”

1. Accept the thumb-sucking.

2. Distract the child by playing checkers.
nu
was not the child’s behavior preoperatively. What is the best
action for the nurse to take?
266.
u
4. “I’ll put on television so you can watch it while I change
the bandage.”
A 6-year-old child is waiting with a family member in the
pediatric clinic for a well-child visit. What are the most
l_
3. Report this behavior to the health care provider. appropriate play activities for the office nurse to offer the
4. Tell the child that thumb-sucking causes buckteeth. child? Select all that apply.
260. Two second-graders are brought to the school health office 1. Coloring book
after a fight during gym class. What should the school nurse 2. Small metal cars
ca

say to the children? 3. Simple card game

1. “Why did you do this?” 4. Large jigsaw puzzle
2. “Tell me what happened.” 5. Children’s magazines
3. “You are both in a lot of trouble.” 267. What toy should a nurse offer two 6-year-old children in
i

4. “How many fights have you two had?” the playroom?

in

261. What should be a school nurse’s first action when a child 1. Clay
tells the nurse of a sore throat? 2. Checkers
1. Examine the throat. 3. Board game
2. Have the child sent home. 4. Building set
cl

3. Take the child’s temperature. 268. A peripheral central venous catheter has just been inserted
4. Secure a prescription for an oral analgesic. in the arm of a 7-year-old child on the pediatric unit.
262. An 8-year-old child who has been receiving chemotherapy A peripheral IV line is still in place. An antibiotic is to
@

will soon return to school after a prolonged absence. Class-
mates are aware that the child is being treated for cancer.
How should the school nurse prepare the class for the child’s
return to school?
1. Encourage the students to think about how they feel
toward their classmate.
2. Explain to the students why it is important to tolerate
those who are different.
3. Ask the students not to make fun of their classmate
because of lost weight and having no hair.
4. Initiate a discussion with the students about cancer treat-
ments and the side effects of chemotherapy.
263. A child who is known to have the human immunodeficiency
u virus (HIV) is admitted to the hospital with the diagnosis
of Pneumocystis jiroveci pneumonia. The nurse administers
be administered immediately. Which intravenous access
line should the nurse use for the antibiotic infusion and
why?
1. Central venous catheter, because this will help determine
its patency
2. Peripheral line, because the central venous catheter is
reserved for fluids
3. Central venous catheter, because the antibiotic must be
given systemically as quickly as possible
4. Peripheral line, because the central venous catheter place-
ment has not been confirmed by radiograph
269. A 9-year-old child who is receiving IV antibiotic
u therapy becomes bored and irritable. What activities for
school-age children should the nurse suggest? Select all that
apply.
730 CHAPTER 35 Child Health Nursing

1. Playing solitaire 276. A 7-year-old child develops a urinary tract infection. A

2. Starting a collection sulfonamide preparation is prescribed. What is a major
3. Making a model airplane nursing responsibility when administering this drug?
4. Doing arithmetic puzzles 1. Weigh the child daily.
5. Watching game shows on television 2. Give the medication with milk.
270. Which fifth-grader who needs help with social inter 3. Monitor the child’s temperature frequently.

­
action should the school nurse appoint as a health
office monitor?
1. One who is reserved, although strong academically
2. The child who has been identified as the class
clown
3. One who comes to the health office daily for
medication
4. The child who participates in a wide variety of school-
4. Administer the drug at the prescribed times.
277. A child is admitted with a diagnosis of acute post streptococ-
u cal glomerulonephritis (APSGN). When performing a phys-
ical assessment and reviewing the child’s laboratory reports,
what clinical findings does the nurse expect? Select all that
apply.
1. Hematuria
2. Proteinuria

g
related activities 3. Periorbital edema
271. What nursing intervention will be most effective to help 4. Increased specific gravity

in
relieve the anxiety of a young school-age child during the 5. Slight increase in blood pressure
postoperative period? 278. When planning nursing care for a 5-year-old child with
1. Encouraging the child to talk about feelings acute post streptococcal glomerulonephritis (APSGN), what

rs
2. Having the child and a parent room together should the nurse emphasize that the child and family
3. Telling the child a story about a child with similar maintain?
surgery 1. A bland diet high in protein
4. Providing the child with sterile dressing equipment 2. Bed rest for at least four weeks

272.
and a doll

Which age group will be most receptive to this

information?
nu
The school nurse is planning to teach a class about nutrition.
3. Isolation from children with infections
4. A daily intramuscular dose of penicillin
279. The parents of a child with acute post streptococcal glo-
merulonephritis (APSGN) tell the nurse that they are con-
l_
1. 6-year-old children cerned about activity restrictions after discharge. How
2. 8-year-old children should the nurse respond?
3. 11-year-old children 1. Activity must be limited for 1 month.
4. 15-year-old children 2. The child should not play active games.
ca

273. Obesity in children is an ever-increasing problem. What
should a nurse consider before confronting the problem
with individual children?
1. Enjoyment of specific foods is inherited.
i
3. The child must remain in bed for 2 weeks.
4. Activity does not affect the course of the illness.
280. The nurse is providing instruction to a parent of a child with
influenza. Which statement by the parent indicates the need

2. Childhood obesity is not usually a predictor of adult for further instruction?

in

obesity. 1. “I will manage the fever with baby aspirin.”

3. Children with obese parents and siblings are destined 2. “We will make sure to get a flu shot next season.”
for obesity. 3. “Providing fluids will help relieve the symptoms.”
4. Familial and cultural influences are deciding factors in 4. “Staying home from school will prevent transmission.”
cl

eating habits. 281. The parents of a child with acute post streptococcal glo-
274. An 11-year-old child has gained weight. The mother tells a merulonephritis (APSGN) ask a nurse why their child is
nurse that she is concerned that her child, who loves sports, being weighed every morning. What is the nurse’s best
@

may become obese. What is the nurse’s most appropriate response?

response?
1. Suggest an increase in activity.
2. Encourage a decreased caloric intake.
3. Explain this is expected during preadolescence.
4. Discuss the influence of genetics on weight gain.
275. A 7-year-old child is admitted for surgery. What is an essen-
tial preoperative nursing intervention?
1. Allow a favorite toy to remain with the child.
2. Document the child’s ASO titer and C-reactive protein
level.
3. Inspect the child’s mouth for loose teeth and report the
findings.
4. Encourage a parent to stay until the child leaves for the
operating room.
1. “It is the best way to measure your child’s fluid balance.”
2. “It provides a measure of how much protein is being
lost.”
3. “The disease process usually is over when weight loss
stops.”
4. “Plans for the daily caloric intake are made according to
the daily weight change.”
282. A 7-year-old child is admitted for a diagnostic workup and
u is transferred from the emergency department to the pedi-
atric unit. The nurse reviews the admission note and physical
assessment. The nurse obtains the child’s vital signs and talks
with the parents. The parents ask the nurse why their child
has severe headaches. What explanation should the nurse
give for the cause of the headaches?
 Review Questions 731

1. Growth
History and Physical
2. Sexuality
7-year-old child
3. Emotions
Reporting general malaise
Experiencing severe headaches 4. Body image
Hematuria 288. A nurse is planning to teach about self-administration of
Admission Note insulin to a school-age child newly diagnosed with diabetes
Tentative diagnosis: acute post streptococcal glomerulonephritis (APSGN) mellitus. What is the nurse’s first action?
Vital Signs 1. Assess the child’s developmental level.
Temperature: 98.2° F 2. Determine the family’s understanding of the procedure.
Pulse: 96 beats/min 3. Discuss community resources for the child in the future.
Respirations: 26 breaths/min 4. Collaborate with the school nurse for ensuring continu-
Blood Pressure: 150/90 mmHg ity of care in school.
289. A nurse is planning a teaching program for a child who has
1. Rapid respirations recently been diagnosed with type 1 diabetes. What is the

g
2. Elevated blood pressure nurse’s first concern relating to the child and parents?
3. Anemia associated with the hematuria 1. Exploring their feelings about diabetes

in
4. Autoimmune response associated with APSGN 2. Needing to restrict the child’s activities
283. A 7-year-old child has recently been diagnosed with juvenile 3. Learning to monitor blood glucose levels
idiopathic arthritis (JIA). The parents are concerned about 4. Practicing administering insulin injections

rs
the lifelong effects of the disorder and are investigating other 290. A nurse is teaching a 12-year-old child with type 1 diabetes
therapies to use with the medications. What referral should about the effects of Novolin N insulin. If the child receives
the nurse recommend? the insulin at 7:30 AM, what time of day is an insulin reac-
1. Physical therapy tion likely to occur?

284.
2. Special education
3. Nutritional therapy
4. Herbal supplements
An 11-year-old child with juvenile idiopathic arthritis (JIA)
nu 1. 8:30 PM
2. 2:30 PM
3. 9:30 AM
4. 1:30 AM
l_
will be receiving continued nonsteroidal antiinflammatory 291. A nurse is planning an evening snack for a child receiving
drug (NSAID) therapy at home. Which important toxic Novolin N insulin. What is the reason for this nursing
effect of NSAIDs must be included in the nurse’s discharge action?
instructions to the child and family? 1. It encourages the child to stay on the diet.
ca

1. Diarrhea 2. Energy is needed for immediate utilization.

2. Hypothermia 3. Extra calories will help the child gain weight.
3. Blood in the urine 4. Nourishment helps to counteract late insulin activity.
4. Increased irritability 292. A nurse is developing a teaching plan for an 8-year-old child
i

285. A nurse is teaching the parents of a child with juvenile who has recently been diagnosed with type 1 diabetes. What
in

u idiopathic arthritis (JIA) how to prevent loss of joint func- developmental characteristic of a child this age should the
tion. Which activities should be encouraged? Select all that nurse consider?
apply. 1. Child is in the abstract level of cognition.
1. Riding a bicycle 2. Child’s dependence on peer influence has reached its
cl

2. Walking to school peak.

3. Watching videos after school 3. Child will welcome opportunities for participation in
4. Swimming in the community pool self-care.
@

5. Playing computer games after school
286. Range-of-motion exercises are prescribed for a child with
juvenile idiopathic arthritis (JIA). What criterion should the
nurse use to evaluate the effectiveness of the exercises?
1. Pain is relieved.
2. Affected joints can flex and extend.
3. Pedal and radial pulses are diminished.
4. Subcutaneous nodules at the joints recede.
287. The parents of a 12-year-old child with juvenile idiopathic
arthritis (JIA) ask a nurse why their child is not receiving
steroid therapy because it is so effective for adults with
rheumatoid arthritis. The nurse responds that it is not used
as the first-choice drug for a preadolescent. On what aspect
of the child’s development should the nurse explain it will
have an adverse effect?
4. Child’s developmental stage involves achieving a sense
of identity.
293. When teaching an adolescent with type 1 diabetes about
dietary management, what should the nurse include?
1. Meals should be eaten at home.
2. Foods should be weighed on a gram scale.
3. Ready source of glucose should be available.
4. Specific foods should be cooked for the adolescent.
294. At 7 AM, a nurse receives the information that an adolescent
with diabetes has a 6:30 AM fasting blood glucose level of
180 mg/dL. What is the priority nursing action at this
time?
1. Encourage the adolescent to start exercising.
2. Ask the adolescent to obtain an immediate glucometer
reading.
732 CHAPTER 35 Child Health Nursing
3. Inform the adolescent that a complex carbohydrate such
as cheese should be eaten.
4. Tell the adolescent that the prescribed dose of rapid
acting insulin should be administered.
295. What treatment should the nurse suggest to an adolescent
with type 1 diabetes if an insulin reaction is experienced
while at a basketball game?
1. “Call your parents immediately.”
2. “Buy a soda and hamburger to eat.”
3. “Administer insulin as soon as possible.”
4. “Leave the arena and rest until the symptoms subside.”
296. One principle to be followed for children with type 1 dia-
betes is to provide for the variability of the child’s activity.
What should the nurse teach the child about how to com-
pensate for increased physical activity?
1. Eat more food when planning to exercise more than
usual.
2. Take oral, not injectable insulin, on days of heavy
exercise.
rs
3. Take insulin in the morning when extra exercise is
anticipated.
4. Eat foods that contain sugar to compensate for the
extra exercise.
297.
nu
A parent receives a note from school that a student in class
has head lice. The parent calls the school nurse to ask how
to check for head lice. What instructions should the nurse
provide?
l_
1. “Ask the child where it itches.”
2. “Check to see if your dog has ear mites.”
3. “Look along the scalp line for white dots.”
4. “Observe between the fingers for red lines.”
ca
298. A 6-year-old child comes to the school nurse reporting a
sore throat, and the nurse verifies that the child has a fever
and a red, inflamed throat. When a parent of the child
arrives at school to take the child home, the nurse urges the
i
parent to seek treatment. The nurse is aware that the caus-
in
ative agent may be beta-hemolytic streptococcus, and the
illness may progress to inflamed joints and an infection in
the heart. What illness is of most concern to the nurse?
1. Tetanus
cl
2. Influenza
3. Scarlet fever
4. Rheumatic fever
@
299. Based on developmental norms for a 5-year-old child, a
nurse decides to withhold a scheduled dose of digoxin
(Lanoxin) elixir and notify the health care provider. Below
what apical pulse did the nurse withhold the medication?
1. 60 beats/min
2. 70 beats/min
3. 90 beats/min
4. 100 beats/min
300. A child has been diagnosed with classic hemophilia. A nurse
teaches the child’s parents how to administer the plasma
component factor VIII through a venous port. It is to be
given 3 times a week. What should the nurse tell them about
when to administer this therapy?
1. Whenever a bleed is suspected
2. In the morning on scheduled days
3. At bedtime while the child is lying quietly in bed
4. On a regular schedule at the parents’ convenience
301. What medication does a nurse expect to administer to
control bleeding in a child with hemophilia A?
1. Albumin
2. Fresh frozen plasma
3. Factor VIII concentrate
4. Factors II, VII, IX, X complex
302. A nurse is explaining how hemophilia is inherited to the
parents of a recently diagnosed child. What is the best
explanation of the genetic factor that is involved?
1. It follows the Mendelian law of inherited disorders.
2. The mother is the carrier of the disorder, but is not
affected by it.
g
3. It is an autosomal dominant disorder in which the
woman carries the trait.
in
4. A carrier can be male or female, but it occurs in the sex
opposite that of the carrier.
303. The parent of a child with hemophilia asks the nurse, “If my
son hurts himself, is it all right if I give him two baby aspi-
rins?” How should the nurse respond?
1. “You seem concerned about giving drugs to your child.”
2. “It is all right to give him baby aspirin when he hurts
himself.”
3. “Aspirin may cause more bleeding. Give him acetamino-
phen instead.”
4. “He should be given acetaminophen every day. It will
prevent bleeding.”
304. A 12-year-old child with Down syndrome is admitted to the
u hospital for intravenous antibiotics for pneumonia. Which
clinical findings associated with Down syndrome should the
nurse expect when performing a physical assessment? Select
all that apply.
1. Saddle nose
2. Thin fingers
3. Inner epicanthic folds
4. Hypertonic musculature
5. Transverse palmar crease
305. An 8-year-old child is diagnosed with Legg-Calvé-Perthe
disease. The health care provider orders an abduction brace
23 hours a day and non-weight-bearing activity. What
should the nurse teach the parents to do?
1. Have the child transfer to a wheelchair using the unaf-
fected leg.
2. Explain that kneeling, but not standing, on the affected
leg is permitted.
3. Perform range-of-motion exercises to the lower extre
­
mities twice a day.
4. Crutches can be used as long as the four-point gait is
used when walking.
Nursing Care of Adolescents
306. An adolescent is admitted to the hospital in respiratory
u distress, and the health care provider orders oxygen at 40%
via a Venturi mask. The instructions for the Venturi mask
indicate 4 L/min: 24% to 28%; 8 L/min: 35% to 40%; and
 Review Questions 733

12 L/min: 50% to 60%. Draw a circle where the ball of the
flow meter should be raised to deliver the percent of oxygen
ordered by the health care provider.
310. A nurse is teaching growth and development to a group of
15
10
1. Encourage the adolescent to take more interest in and
responsibility for treatment.
2. Speak separately with each of them, encouraging them
to recognize and vent their anger.
3. Try to persuade the two of them to work out their dif-
ferences together before returning to the clinic.
4. Ask the parent to stay in the waiting room while the
adolescent meets with the clinic’s staff members.
parents. When discussing puberty, one parent asks at what
age a girl will get her first period. How should the nurse
respond?
1. Before the pubic hair appears
2. About the same time the breasts develop

g
3. At the end of the prepubertal growth spurt
5 4. Near the age the mother had her first period

in
311. A 13-year-old female adolescent comes to the pediatric
1
u clinic, and her body mass index (BMI) is 21. Compare the
adolescent’s BMI to the body mass index-for-age percentiles

rs
for girls, 2 to 20 years, graph and determine what percentile
this adolescent falls under. Record your answer using a
whole number.
Answer: _________%

en S
nu
hu
Op

OXYGEN
BMI BMI
Flo
w meter
Body mass index–for-age percentiles:
l_
97th

34
Girls, 2 to 20 years 34

32 95th 32
307. After orthopedic surgery, a 15-year-old adolescent reports a
ca

pain rating of 5 on a scale of 0 to 10. A nurse administers 30 30

the prescribed 5 mg of oxycodone every 3 hours prn. Two

hours after having been given this medication, the adoles- 28
90th
28

cent reports a pain rating of 10 out of 10. What action

i

85th
should the nurse take? 26 26
in

1. Administer another dose of oxycodone within 30

75th
minutes. 24 24

2. Report that the adolescent has an apparent idiosyncrasy

to oxycodone. 22 22
cl

50th

3. Tell the adolescent that additional medication cannot be

given for 1 more hour. 20
25th
20

4. Request that the health care provider evaluate the need 10th
@

18 18
for additional medication. 5th
3rd

308. An adolescent is hospitalized for dehydration. An IV of

16 16
u 1000 mL of 0.9% sodium chloride with 20 mEq/L of potas-
sium chloride is prescribed. A 500 mL bag of 0.9% sodium 14 14
chloride is available. The potassium chloride label reads
2 mEq/mL. How many milliliters of potassium chloride 12 12

should the nurse add to the 500 mL bag? Record your

answer using a whole number. kg/m2 kg/m2

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Answer: __________ mL Age (years)

309. A 15-year-old adolescent who has type 1 diabetes arrives at

the diabetic outpatient clinic with a parent. The adolescent
sits back in the chair with arms folded, frowns, and displays
an “I don’t care” attitude. The adolescent and parent argue
in front of the nurse. What is the best approach for the nurse
to use?
312. A nurse is interviewing an adolescent who is to start on a
chemotherapeutic drug regimen that includes vinCRIStine.
For which side effect is it most important for the nurse to
prepare the adolescent?
734 CHAPTER 35 Child Health Nursing
1. Alopecia
2. Constipation
3. Loss of appetite
4. Peripheral neuropathy
313. How can a nurse best accomplish therapeutic communica-
tion with an adolescent?
1. Using teen language
2. Relating on a peer level
3. Establishing a relationship over time
4. Interacting by using concrete concepts
314. A nurse is planning to discuss the importance of following
the prescribed course of treatment with a group of adoles-
cent clients. What should the nurse first consider about
their approach to illness and treatment?
1. They are in touch with their feelings and concerns.
2. Their thinking is both concrete and reality oriented.
3. They are involved more with the present than the future.
4. Their developmental goal is striving for industry versus
inferiority.
rs
315. A nurse is teaching a group of parents about a developmental
expectation that occurs in girls at about 10 years of age.
What should the nurse explain about one of the earliest signs
of sexual maturity?
1. Interest in the opposite sex
nu
2. Paying attention to grooming
3. The first menstrual period or menarche
4. The appearance of axillary and pubic hair
l_
316. An adolescent sustains a sports-related fracture of the femur,
and an open reduction and internal fixation with a rod
insertion is performed. After the surgery, a nurse identifies
that the adolescent is very upset. Considering the develop-
ca
mental level, what does the nurse conclude is the most likely
explanation for this distress?
1. The need to navigate in a wheelchair
2. The perception that the rod is a body intrusion
i
3. Inability to participate in sports for several years
in
4. Relief of pain will necessitate medication until the bone
heals
317. A 13-year-old adolescent is diagnosed as having idiopathic
scoliosis. Because exercise and avoidance of fatigue are essen-
cl
tial components of care, which sport should the nurse
suggest will be most therapeutic for this preadolescent?
1. Golf
@
2. Bowling
3. Swimming
4. Badminton
318. To slow the progression of the curvature, the preadolescent
with scoliosis is fitted with a brace. How should the nurse
respond to the parents’ questions about when the brace will
no longer be needed?
1. After cessation of bone growth
2. After the curvature has straightened
3. When the iliac crests are at equal levels
4. When pain-free after prolonged standing
319. An adolescent who is receiving chemotherapy for the treat-
u ment of bone cancer has stomatitis as a result of chemo-
therapy. What should the nurse include when teaching the
child about self-care? Select all that apply.
1. Clean the teeth with a swab.
2. Drink fluids through a straw.
3. Brush the teeth three times a day.
4. Rinse frequently with a mouthwash.
5. Avoid food that has extremes in temperature.
320. A nurse on the adolescent unit is planning to discuss
smoking prevention. What is the most effective approach
for the nurse to use?
1. Share personal experiences with a smoking cessation
program.
2. Show pictures of the effects of smoking on the cardio-
pulmonary system.
3. Present information on how smoking affects appearance
and odor of the breath.
g
4. Cite statistics about the relationship between smoking
and cardiopulmonary diseases.
in
321. An adolescent with a serious health problem refuses to wear
a medical alert bracelet. How can a nurse foster wearing of
the bracelet?
1. Recommend hiding the bracelet under long-sleeved
clothes.
2. Suggest wearing the bracelet when engaging in con
­
tact sports.
3. Encourage the teenager to ask friends to wear simi
­
lar bracelets.
4. Help the teenager select a bracelet that is similar to those
worn by peers.
322. A 13-year-old boy tells the school nurse that he is getting
breasts. How should the nurse respond?
1. “This is expected at your age; let’s talk about it.”
2. “You should get a physical; I’ll talk with your parents
about this.”
3. “There is nothing to worry about; this happens to a lot
of boys your age.”
4. “Wear a tight undershirt inside a button-down shirt; that
should hide them.”
323. An adolescent arrives at the clinic reporting experiencing
buzzing in the ears. What assessment data are essential for
the nurse to obtain?
1. Music preferences
2. Childhood ear infections
3. Recent emotional trauma
4. Familial history of deafness
324. An adolescent with terminal cancer tells the home care
nurse, “I would really like to get my high school equivalency
diploma. Do you think this is possible?” What is the nurse’s
best approach in response to the adolescent’s question?
1. Refocus the conversation on things the adolescent has
already accomplished in life.
2. Try to help the adolescent understand that this wish is
too taxing and slightly unrealistic.
3. Arrange for a conference with the school and encourage
the adolescent to prepare for the test.
4. Suggest to the adolescent that this energy should be
directed toward expressing feelings about the illness.
325. A 17-year-old adolescent with a history of asthma is brought
u to the emergency department in respiratory distress. A nurse
immediately places the client in a bed with the head of the
 Answers and Rationales 735

bed elevated and administers oxygen via a facemask. The

Physical Assessment

CHILD HEALTH NURSING

health care provider performs a physical assessment, writes
Dyspnea; flaring of nares; productive cough; sputum is frothy, clear, and gelatinous;
orders, and admits the adolescent to the pediatric unit.
wheezing. Adolescent indicates shortness of breath, chest discomfort, headache, and
feeling tired What is the nurse’s priority intervention?
Health Care Provider’s Orders 1. Administering the nebulizer treatment to facilitate
Bed rest breathing
Complete blood count 2. Obtaining a blood specimen to send to the laboratory
SMA 12 for tests
Albuterol (Proventil) 2.5 mg via nebulizer, one dose 3. Notifying the respiratory therapist to perform chest phy-
Chest physiotherapy bid siotherapy

ANSWERS AND RATIONALES

Incentive spirometer 4. Sending a requisition to central supply for an incentive
Oxygen via mask at 8 liters spirometer
Referral to allergist
Vital Signs

g
Temperature: 98.8° F
Pulse: 108 beats/min
Respirations: 30 breaths/min

in
Blood Pressure: 130/86

rs
nu
l_
ANSWERS AND RATIONALES

Nursing Care of Infants Client Need: Management of Care; Cognitive Level: Application;
ca

Nursing Process: Evaluation/Outcomes; Reference: Ch 29,

1. Answer: 4.5 mL. To determine the dose, multiply
15 mg × 9.6 kg = 144 mg. Use the “Desired over Have”
formula of ratio and proportion to solve this problem.
i
Nursing Care Related to Meeting the Needs of the Family of a Child
with Special Needs
3. 3 The family members are more inclined to share
problems with the nurse if they are not feeling

pressured; in addition, it aids in the development of

Desired 144 mg x mL
in

= a productive relationship.
Have 160 mg 5 mL 1 The father should be included in the visit if at all
160 x = 720 possible. 2 This may be an inconvenient time for the
x = 720 ÷ 160
cl

mother and interfere with productivity. 4 This may be

x = 4.5 mL at a time that is inconvenient for the family and thus
interfere with productive interaction.
Client Need: Pharmacological and Parenteral Therapies; Cognitive Client Need: Management of Care; Cognitive Level: Application;
@

Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 2,
Basics of Nursing Practice, Medication Administration, Nursing
Responsibilities Related to Medication Administration
2. 4 Based on the family’s decision, extraordinary care
does not have to be employed; the infant’s basic
needs are met, and nature is allowed to take its
course.
1 If the infant’s physical needs are met and comfort is
provided, the infant’s rights are not ignored;
“extraordinary,” not “all,” care is being withheld.
2 Euthanasia is a deliberate intervention to cause death.
3 It is not illegal to withhold extraordinary treatment;
once such treatment is started, it may become a legal
issue.
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 29, Nursing Care Related to Meeting
the Needs of the Family of a Child with Special Needs
4. 2 A pacifier should be given during the feeding to
help the infant associate sucking with feeding and
to meet oral needs.
1 This will cause complications if the tube is not in the
stomach. 3 This should be done after placement of the
tube and verification of a residual return. 4 Upright
positioning is essential to prevent regurgitation or reflux
and subsequent aspiration.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation; Reference: Ch 30, Hospitalization of
Infants, General Nursing Care of Infants
 736 CHAPTER 35 Child Health Nursing
5. 1 This helps and encourages parents to put their fears
CHILD HEALTH NURSING
and feelings into words. Once these sentiments are
expressed, they can then be examined and
addressed.
2 This will not assist the parents in coping with the
problem, nor will it demonstrate the supportive,
empathetic role of the nurse. 3 This response lacks
insight. Parents will worry about their infant anyway.
4 This may or may not be helpful.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
ANSWERS AND RATIONALES
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 29, Nursing Care Related to Meeting
the Needs of the Family of a Child with Special Needs
6. 3 When taking a health history, all areas of concern
should be explored fully before deciding how to
address the problem.
1 The nurse should gather more data to determine the
basis for the problem. 2 More data are needed before
recommendations can be made. 4 The data are
inadequate to focus on nutrition.
rs
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 29, Age Related Responses to Pain, Infant
nu
7. 3 A respiratory rate of less than 30 breaths/min in a
young infant is not within the expected range of 30
to 60 breaths/min; a drop to less than 30 breaths/
min is a significant change and should be
l_
documented.
1 Respirations will accelerate when there is discomfort.
2 Any significant change should be reported
immediately. 4 The respiratory tract is fully developed at
ca
birth, and the respiratory rate is a cardinal sign of the
infant’s well-being.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
i
Process: Evaluation/Outcomes; Reference: Ch 29, Characteristics of
in
Growth, Respiratory System
8. Answer: 1, 2, 3.
1 This may limit the occurrence of intestinal cramping.
2 This reduces the amount of air entering the intestine,
cl
which may limit the occurrence of intestinal cramping.
3 Providing warmth through a hot-water bottle or
heating pad over the abdomen may be helpful for some
@
infants because it helps to relax the abdominal muscles
and limit intestinal cramping. 4 Although many people
try this remedy, it rarely works. 5 A quiet environment
may help prevent, not treat, the problem.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Caring; Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 30, Colic, Nursing Care
9. Answer: 30 inches. This infant is 2 inches shorter than
expected. At 1 year of age an infant should have
increased the birth length by 50%; 50% of 20 inches is
10 inches; 10 inches added to the birth length of 20
inches equals 30 inches.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Growth and Development, Ten to Twelve Months
10. 1 Sucking meets oral needs, which are primary during
infancy.
2 An infant a few days old is too young to focus well on
a mobile; in addition, the newborn will be placed in a
side-lying position postoperatively and thus would not be
able to see the mobile. 3 A 2-day-old infant is not
developmentally capable of enjoying a soft, cuddly
toy. 4 This is not a developmental need.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Hospitalization of Infants, General Nursing Care of Infants
11. Answer: 2, 4.
1 Infants who have failure to thrive usually are quiet and
g
lethargic. 2 These children usually have developmental
delays, including language, motor, social, and adaptive
in
deficits. 3 Their weight usually is below the fifth
percentile. 4 Infants who have failure to thrive usually are
frail and are at risk for physical and emotional illnesses.
5 Responsiveness to stimuli is limited or nonexistent.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30, Failure
to Thrive, Data Base
12. 4 Excessively high temperatures can damage the
delicate skin of an infant.
1 Although infants are capable of putting small things in
their mouths, they are not yet able to crawl and probably
will not be placed on the floor. 2 At 3 months of age
infants are not yet able to explore the environment to
the point that electric outlets pose a problem.
3 At 3 months of age infants are still too small and have
not yet developed motor capabilities to get into
containers of poison.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Injury
Prevention during Infancy
13. 2 Muscular coordination and perception are
developed enough at 6 months for the infant to roll
over. If unaware of this ability, the parent may leave
the infant unattended for a moment to reach for
something, and the infant could roll off an elevated
surface.
1 Sitting up unsupported is accomplished by most
infants at 7 to 8 months. 3 Crawling takes place at
about 9 months of age. 4 Standing by holding on to
furniture is accomplished by most infants between 8 and
10 months of age.
Client Need: Safety and Infection Control; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Injury
Prevention during Infancy
14. 4 The 7-month-old infant is accustomed to having the
perineal area exposed and cared for and is not in a
developmental stage where fears related to
sexuality are present.
1 A “clean catch” at this age is often contaminated; a
catheterization has been ordered. 2 The parents do have
the right to refuse, but this concern is not realistic for

this age infant. 3 The parent’s concern is not appropriate
for the developmental age of the infant.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Hospitalization of Infants, Data Base
15. 1 The bottom incisors are the first teeth to erupt at
about 6 to 8 months of age.
2 The canine teeth appear at about 18 months. 3,
4 The first molars, both upper and lower, appear at
about 20 months.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Growth and Development, Six to Seven Months
16. 1 This position offers the lowest risk for sudden infant
death syndrome (SIDS).
2, 3, 4 The American Academy of Pediatrics does not
recommend the lateral position because the infant can
fall forward into the prone position.
Client Need: Safety and Infection Control; Cognitive Level:
rs
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Sudden
Infant Death Syndrome, Data Base
17. 2 A common sign of shaken baby syndrome (SBS) is
apnea without stridor or adventitious sounds,
resulting from CNS trauma.
1 The age of the infant is beyond the time that
respiratory distress caused by immaturity would
nu
l_
occur. 3 Short periods of apnea of less than 15 seconds
are expected at any age. 4 These findings are indicative
of laryngotracheobronchitis, which is common in
children younger than 5 years of age, but would not be
ca
expected at 3 months.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Shaken Baby Syndrome, Data Base
i
18. 1 Grunting and rapid respirations are signs of
in
respiratory distress in an infant. Grunting is a
compensatory mechanism whereby the infant
attempts to keep air in the alveoli to increase
arterial oxygenation; increased respirations
cl
increase oxygen and carbon dioxide exchange.
2 Sweating in infants usually is scant because of
immature functioning of the exocrine glands; profuse
@
sweating rarely is seen in a sick infant. 3 This is not
necessarily a sign of illness. 4 This is not necessarily
indicative of illness.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Respiratory
Tract Infections, Data Base
19. 2 Choanal atresia is a lack of an opening between
one or both of the nasal passages and the
nasopharynx.
1 Rectal atresia involves the rectum ending in a pouch
and the anal canal opening into the other
(nonconnected) end of the rectum. 3 Atresias associated
with the gastrointestinal tract include esophageal and
intestinal atresia involving the ileum, jejunum, or
Answers and Rationales 737
colon. 4 An atresia involving the pharynx and larynx is
CHILD HEALTH NURSING
not commonly seen.
Client Need: Physiological Adaptation; Cognitive Level:
Knowledge; Nursing Process: Assessment/Analysis; Reference: Ch
30, Nasopharyngeal and Tracheoesophageal Anomalies, Data Base
20. 1 There is little or no opening between the nasal
passages and the nasopharynx; therefore, the
infant can breathe only through the mouth. When
feeding, the infant cannot breathe without
aspirating some of the fluid; this causes choking.
ANSWERS AND RATIONALES
2 The swallowing reflex is present in these
infants. 3 Because it is difficult if not impossible to
suck, the infant will be hungry. 4 If choanal atresia is
unilateral, there may be no symptoms, and the infant
g
will be able to feed; if bilateral, sucking will be almost
impossible.
in
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 30, Nasopharyngeal and Tracheoesophageal Anomalies, Data Base
21. Answer: 4, 1, 5, 2, 3.
4 A patent airway and adequate pulmonary ventilation are
always the priorities; inadequate oxygenation can result in
cerebral anoxia. 1 Vital signs, including heart rate, are
called vital because they reflect the cardiopulmonary and
hemodynamic status of a person. 5 Replenishment of body
fluids is a significant intervention after surgery; the patency
of the catheter must be maintained and the flow rate
monitored to ensure that an excessive amount is not
instilled and affect the delicate fluid balance in an
infant. 2 The operative site should be monitored for signs
of hemorrhage but after the vital signs. An increase in the
heart and respiratory rates and a decrease in blood pressure
may indicate bleeding. 3 The urinary output should be
monitored hourly. This comes after airway, breathing, and
circulation, signs of bleeding, and interventions that can
influence these vital signs are monitored.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Evaluation/Outcomes; Reference: Ch 30,
Cardiac Malformations, General Nursing Care of Children with Cardiac
Malformations
22. 3 The priority is a patent airway; necessary
equipment must be immediately available.
1 Although this is helpful, it is not the priority. 2 This
is unnecessary; it may be done if the child has a high
fever or a history of febrile seizures. 4 Although
appropriate, this is not the priority.
Client Need: Management of Care; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Respiratory Tract Infections, Nursing Care
23. 4 Laryngeal spasms can occur abruptly; patency of
the airway is determined by constant assessment
for signs of respiratory distress.
1, 2, 3 This is important, but is not the priority.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Respiratory Tract Infections, Nursing Care
24. 2 Often the infant will have decreased pulmonary
reserve, and the clustering of care is essential to
provide for periods of rest.
 738 CHAPTER 35 Child Health Nursing
1 Antiviral therapy is controversial for this age group
CHILD HEALTH NURSING
and is not given unless there are complications. 3 IV
fluids are given during the acute phase to prevent
dehydration. 4 Antitussive agents are not used; nasal
secretions are aspirated with a bulb syringe whenever
necessary.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Respiratory Tract Infections, Nursing Care
25. Answer: 1.5 mL. Use the “Desired over Have” formula
ANSWERS AND RATIONALES
of ratio and proportion to solve this problem.
Desire 375 mL x mL
=
Have 250 mL 1 mL
250 x = 375
x = 375 ÷ 250
x = 1.5 mL
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
rs
Reference: Ch 2, Basics of Nursing Care, Medication Administration,
Nursing Responsibilities Related to Medication Administration
26. 1 Rest reduces the need for oxygen and minimizes
metabolic needs during the acute, febrile stage of
the disease.
2 The child requiring hospitalization for pneumonia
nu
usually is confined to bed and needs to reduce activity to
conserve oxygen. 3 This is not a priority; the child is
l_
expected to be anorectic during the febrile phase.
4 Elimination usually is not a problem, except as a result
of immobility.
Client Need: Basic Care and Comfort; Cognitive Level:
ca
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Respiratory Tract Infections, Nursing Care
27. 3 Respiratory syncytial virus (RSV) is highly
contagious. The infant should be isolated or placed
i
with other infants with RSV. Standard and contact
in
precautions are instituted to limit the spread of
pathogens to others.
1 The infant should receive cool, humidified oxygen
either by nasal cannula, by mask, or in a croup tent.
cl
2 Because RSV is extremely contagious, the number of
visitors should be limited. Uninfected children should
not be allowed near the infant, and as few personnel as
@
possible should care for the infant. 4 Antibiotics are not
effective and their use is contraindicated.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Respiratory Tract Infections, Nursing Care
28. 3 The bladder membrane is exposed; it must remain
moist and, as far as possible, sterile.
1, 2 This will allow the exposed membrane to dry and
increase the risk for infection. 4 The jelly will adhere to
the membrane, causing trauma.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Exstrophy of the Bladder, Nursing Care
29. 4 The pubic bone and the bladder form during the
same time of embryonic development.
1, 2, 3 This defect is not associated with exstrophy of
the bladder.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Exstrophy of the Bladder, Data Base
30. 1 The greatest problem facing this infant is infection
of the bladder mucosa and excoriation of the
surrounding tissue; meticulous hygiene is necessary
both preoperatively and postoperatively.
2 Dehydration is not a problem because fluid intake and
the amount of urinary output are not affected.
3 Urinary retention is not a problem because the urine
drains continuously. 4 The congenital abnormality
involves the genitourinary system, not the intestines.
g
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
in
30, Exstrophy of the Bladder, Nursing Care
31. 1 This provides for collection of more data.
2 This implies that things are not well and that the
mother may be to blame. 3 This may make the mother
feel guilty about not meeting her baby’s needs. 4 This is
a negative comment that closes communication.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Caring;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Exstrophy of the Bladder, Nursing Care
32. 1 Mumps can cause orchitis (inflammation of the
testes) in males and oophoritis (inflammation of the
ovaries) in females. Although rare, both can render
the postpubescent child sterile.
2, 3, 4 This is not associated with mumps.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Immunizations
33. 3 Cardiac anomalies often accompany genetic
problems such as Down syndrome; 30% to 40% of
these infants have congenital heart defects.
1 These infants do not have increased intracranial
pressure; the fontanels should be flat. 2 The extremities
will more likely be relaxed. 4 They have the usual
pupillary reactions to light.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Trisomy 21, Data Base
34. 4 Touching the palms of the hands causes flexion of
the fingers (grasp reflex); this usually lessens
after 3 months of age. An unexpected loud noise
causes abduction of the extremities and then
flexion of the elbows (startle reflex); this usually
disappears by 4 months of age. Persistence of
primitive reflexes usually is indicative of a
developmental delay.
1 It is not necessary to gather more data because these
changes are consistent with expected growth and
development. 2 The data do not support making this
comment; this may cause needless concern. 3 Sensory
stimulation at this age is directed toward experiences to
add new motor, language, and social skills.

Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Growth and Development, Two to Three Months
35. 4 The Hib vaccine may cause a low-grade fever.
1 Lethargy is not expected. 2 Urticaria is more likely to
occur with the tetanus and pertussis vaccines. 3 There
may be a mild reaction at the injection site, but a
generalized rash is not expected.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 30, Immunizations
36. Answer: 50 mL. The correct rate is 50 mL/hr. Divide the
total volume to be infused (400 mL) by the number
of hours it is to be infused (8): 400 ÷ 8 = 50 mL.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 3, Fluid, Electrolyte, and Acid-Base Balance, General
Nursing Care of Clients with Fluid and Electrolyte Problems
37. 4 The extracellular body fluid represents 45% at
rs
birth, 25% at 2 years of age, and 20% at maturity.
Another measurement is fluid’s percentage of total
body weight, which is 80% at birth, 63% at 3 years,
and approximately 60% at 12 years.
nu
1 Cellular metabolism in children is stable, but its rate is
higher than that in adults. 2 The proportion of total
body water in children (up to 2 years) is greater than it is
in adults. 3 Renal function is immature through the
l_
second year of life, not until school age, which makes it
more difficult to maintain fluid balance.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
ca
Nursing Process: Assessment/Analysis; Reference: Ch 29,
Characteristics of Growth, Circulatory System
38. 1 Febrile seizures usually are not associated with
major neurologic problems. From 95% to 98% of
i
these children do not develop epilepsy or other
neurologic problems.
in
2 The cause of febrile seizures is still uncertain. 3 Most
febrile seizures occur after 6 months of age and before
age 3 years, with the average age of onset between 18
cl
and 22 months. 4 Boys are affected about twice as
frequently as girls.
Client Need: Health Promotion and Maintenance; Cognitive
@
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Febrile Seizures, Data Base
39. 1 Shivering increases the metabolic rate, which
intensifies the body’s need for oxygen and
increases the body temperature.
2 Restricting fluids is contraindicated because of the risk
for dehydration; fluids should be offered. 3 Although
monitoring output will provide information about the
child’s level of hydration, it is more important to take
action to prevent increases in the fever. 4 Although
monitoring vital signs is important, it is not the priority.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Febrile Seizures, Nursing Care
Answers and Rationales 739
40. 3 Because the child is in a crib, the nurse should
CHILD HEALTH NURSING
remain, observe, and protect the child from injury
to the head or extremities during seizure activity.
1 An individual should never be restrained during a
seizure; fractured bones or torn muscles and ligaments
can result. 2 This is useless until the seizure is over; the
child is apneic during the seizure. 4 Attempts at
inserting an airway are futile; this may damage the child’s
teeth and jaws.
Client Need: Physiological Adaptation; Cognitive Level:
ANSWERS AND RATIONALES
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Febrile Seizure, Nursing Care
41. 2 This limits the danger of falling and striking the
head.
g
1 This is unsafe; attempting to open the jaw may result
in injury. 3 Protecting the child is the priority;
in
assistance at this time is futile. 4 This may cause airway
occlusion by forcing the chin onto the neck.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Febrile Seizure, Nursing Care
42. Answer: 1, 2.
1 Irritability is a classic sign of increased intracranial
pressure because of disruption of the central nervous
system (CNS). 2 Bradycardia is a classic sign of
increased intracranial pressure; it is a late sign. 3 With
increased intracranial pressure, there is decreased alertness
or loss of consciousness. 4 The pulse pressure increases
with increased intracranial pressure. 5 The systolic blood
pressure increases with increased intracranial pressure.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30,
Meningitis, Data Base
43. 4 This is what occurs in communicating
hydrocephalus.
1 This is often caused by a choroid plexus tumor and
does not interfere with the flow of cerebrospinal fluid
(CSF) through the ventricles. 2 This is an inaccurate
answer; brain cells and the spinal cord are not
involved. 3 This reflects the pathophysiologic process of
noncommunicating hydrocephalus.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 30, Hydrocephalus, Data Base
44. 2 The other children need to be involved with the
grieving process and work through their own
feelings.
1 This is a long-term goal. 3 It is too early for this
goal. 4 It is premature for this goal; also, they may
never achieve this goal.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Sudden Infant Death Syndrome, Nursing Care
45. 2 Elevation of the head helps decrease intracranial
pressure by the use of gravity.
1 This is done after the insertion of a shunt; if the infant
is in the intensive care unit, this is done routinely.
 740 CHAPTER 35 Child Health Nursing
3 This may be disturbing to the infant and impair the
CHILD HEALTH NURSING
ability to rest. 4 Frequent stimulation may cause further
irritability to an already traumatized central nervous
system (CNS).
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Hydrocephalus, Nursing Care
46. 2 Shunts are revised, and the length of the tubing is
increased as the child grows.
1 Although treatment of hydrocephalus by shunt
ANSWERS AND RATIONALES
replacement is quite successful, there is danger of
malfunction and infection of the shunt. 3 Some brain
damage may be reversible during the first year of
life. 4 Hydrocephalus necessitates treatment for the life
of the child.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 30, Hydrocephalus,
Nursing Care
47. 4 The shunt may obstruct and lead to an accumulation
rs
of cerebrospinal fluid (CSF) in the head; the
accumulated fluid increases the intracranial
pressure, which leads to brainstem hypoxia.
resulting from too rapid reduction of intracranial
fluid. 2 Although pain management is essential to
nu
1 Positioning the infant flat helps prevent complications
minimize an increase in intracranial pressure, sedation is
contraindicated because it will mask the infant’s level of
l_
consciousness (LOC). 3 The infant is positioned on the
opposite side from the shunt to prevent pressure on the
valve and incisional area.
Client Need: Reduction of Risk Potential; Cognitive Level:
ca
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 30, Hydrocephalus, Nursing Care
48. 3 The affected limbs should be exercised to promote
circulation and prevent atrophy.
i
1 Development should be encouraged; the infant’s
in
movements should not be restricted. 2 Fluids should be
encouraged to provide adequate kidney function and
prevent constipation. 4 The infant needs stimulation to
develop mentally and socially.
cl
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 30, Hydrocephalus,
@
Nursing Care
49. Answer: 1, 3, 4.
1 A low-grade fever progressing to a high fever
occurs. 2 Irritability rather than lethargy results. 3 An
infectious process that causes meningitis may result in
rigidity and hyperextension of the neck (opisthotonos).
4 Central nervous system (CNS) irritation results in
irritability and anorexia. 5 The fontanels will be tense or
bulging as increased intracranial pressure progresses.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30,
Meningitis, Data Base
50. 4 The anterior fontanel will be widened and tense
because of the increased volume of cerebrospinal
fluid (CSF).
1 The pulse rate will be decreased with increased
intracranial pressure. 2 The reflexes will be hyperactive
with increased intracranial pressure. 3 The blood
pressure will be higher with increased intracranial
pressure.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 30, Hydrocephalus, Nursing Care
51. 1 These infants need follow-up care with a variety of
health care providers (e.g., neurologist, physical
therapist) to manage the child’s condition during
growth and development.
2 This is unnecessary. 3 Powder should be avoided; it
will create a pastelike substance when mixed with urine
g
and when aerosolized it is a respiratory irritant. 4 These
children require more frequent perineal care than just
in
routine cleansing and diaper changes.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Defects of
Neural Tube Closure, Nursing Care
52. 2 A meningomyelocele is thinly covered and fragile;
trauma to the sac can damage functioning neural
tissue; an intact sac reduces a potential portal of
entry for microorganisms.
1 Although extremely important, it is not the priority;
care of the sac is even more important because an intact sac
reduces a portal of entry for microorganisms. 3 Although
observation for paralysis is an important nursing measure,
it is not the priority. 4 The extent of a meningomyelocele
will influence the child’s ability to control these functions,
but control is not developed until the toddler and
preschool years.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Defects of Neural Tube Closure,
Nursing Care
53. 2 This is the best position for preventing pressure on
the sac.
1 Diapers should not be applied because they might
irritate or contaminate the sac. 3 Assessment of the area
below the defect is essential to determine motor and
sensory function. 4 There is no indication for the use of
an antiseptic.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Defects of Neural Tube Closure,
Nursing Care
54. 3 The surgical closure of the sac decreases the
absorptive surface and eliminates a route by which
the spinal fluid drains. Since the cranial sutures
have not closed, the skull will expand if fluid
increases, causing hydrocephalus.
1 The lower extremities of most infants with
myelomeningocele are partially or completely paralyzed;
performing careful range-of-motion exercise is an
important part of nursing care. 2 There is no reason to
decrease environmental stimuli for infants who have had
surgical correction of a myelomeningocele unless they

also have seizures. 4 This is not expected, because
damage to the meninges of the brain is not a factor in
the surgical treatment of myelomeningocele.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 30, Defects of Neural Tube Closure, Nursing Care
55. 4 Infections of cranial structures can cause meningitis
because bacteria travel by direct anatomic route to
the meninges and cerebrospinal fluid (CSF).
1, 2, 3 This part of the body does not come into
contact with CSF.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Meningitis, Data Base
56. Answer: 1, 3, 2, 4, 5.
1 Bacterial meningitis is transmitted through respiratory
droplets. The nurse should first ensure that all who come
in contact with the child are appropriately gowned,
gloved, and masked. 3 A circulatory access device
provides an avenue to administer prescribed fluids and/or
rs
medications; also, it provides a circulatory access in case
of an emergency. 2 The next priority is to obtain a
sample of cerebral spinal fluid (CSF). This will help
nu
determine if the etiology is viral or bacterial, and the
appropriate pharmacological therapy can be prescribed by
the health care provider. 4 Once the CSF sample is
obtained and the diagnosis is confirmed, the health care
provider can prescribe the antibiotic that will most likely
l_
be appropriate for the causative microorganism. An
antibiotic cannot be administered before it is prescribed.
5 Nuchal rigidity (neck stiffness) occurs as the disease
ca
progresses; it is not an initial sign of meningitis.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Meningitis, Nursing Care
57. 4 Most children are no longer contagious after 24 to
i
48 hours of receiving IV antibiotics.
in
1 This time period is inadequate even if antibiotics are
started immediately. 2, 3 This is an excessive time period
and is unnecessary.
Client Need: Safety and Infection Control; Cognitive Level:
cl
Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 30, Meningitis, Nursing Care
58. 2 The blood-brain barrier is affected, which permits
@
the passage of protein into the cerebrospinal fluid
(CSF).
1 The cell count will be increased. 3 Glucose levels are
decreased in proportion to the duration of the
disease. 4 Spinal fluid pressure will be increased.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference: Ch
30, Meningitis, Data Base
59. 3 Meningococcal meningitis is identified by its
epidemic nature and purpuric skin rash.
1, 4 This is not characteristic of meningococcal
meningitis. 2 The fever of meningitis is usually high.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Meningitis, Data Base
Answers and Rationales 741
60. Answer: 1, 2, 5.
CHILD HEALTH NURSING
1 Irritation of cerebral tissue can cause seizures.
2 Pressure on vital centers can cause vomiting.
3 A 2-year-old child’s fontanels are closed, so bulging
fontanels are not a sign of increased intracranial
pressure. 4 The inflammatory process of meningitis
causes an elevated temperature. 5 Pressure on the
respiratory center results in a decreased respiratory rate.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30,
ANSWERS AND RATIONALES
Meningitis, Data Base
61. 3 Peripheral circulatory collapse (Waterhouse-
Friderichsen syndrome) is a serious complication of
meningococcal meningitis caused by bilateral
g
adrenal hemorrhage. The resultant acute
adrenocortical insufficiency causes profound shock,
in
petechiae, ecchymotic lesions, vomiting,
prostration, and hypotension.
1 Although epilepsy may occur, it is controllable and not
as serious as peripheral circulatory collapse. 2 Although
blindness may occur, it is not as serious a complication
as peripheral circulatory collapse. 4 Although
hydrocephalus may occur, it is rare and not as serious as
peripheral circulatory collapse.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 30, Meningitis, Data Base
62. 4 Asymmetry of the gluteal dorsal surface of
the thighs and inguinal folds indicates
developmental dysplasia of the hip; folds on the
affected side appear higher than those on the
unaffected side.
1 An inguinal hernia is evidenced by protrusion of the
intestine into the inguinal sac. 2 Impaired reflex
behavior and a shrill cry indicate central nervous system
damage. 3 Peripheral nervous system damage is
manifested by limpness or flaccidity of extremities.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Developmental Dysplasia of the Hip, Data Base
63. 4 A foul smell emanating from the cast indicates
development of an infection and requires
immediate treatment.
1 Soiling of the cast with excreta, although problematic,
is not a serious complication. 2 This is not necessary,
nor is it desirable. 3 The infant’s position should be
changed frequently.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Developmental Dysplasia of the Hip, Nursing Care
64. 1 Standard seat belts and car seats are not readily
adapted for use by children in spica casts; specially
designed devices are available to meet safety
requirements.
2 Other strategies in addition to diapers will be
necessary to keep the cast clean. 3 This is inadequate;
the position should be changed at least every 2 hours.
4 Using the abduction bar for lifting or turning can
 742 CHAPTER 35 Child Health Nursing
weaken the cast; the bar is designed to keep the hips in
CHILD HEALTH NURSING
alignment.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Developmental Dysplasia of the Hip, Nursing Care
65. 4 When elevation of the head is desired, the entire
mattress or crib should be raised at the head of the
crib.
1 There is no reason to place such a short time limit on
this position. 2 Pillows under the head or shoulders of a
ANSWERS AND RATIONALES
child in a spica cast will thrust the chest forward against
the cast, causing discomfort and respiratory distress.
3 This will not help elevate the infant’s head.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Developmental Dysplasia of the Hip, Nursing Care
66. 4 Congenital hypothyroidism is the result of
insufficient secretion by the thyroid gland because
of an embryonic defect. Decreased thyroid hormone
rs
affects the fetus before birth during cerebral
development, so it is likely that there will be some
cognitive impairments at birth. Treatment
before 3 months will prevent further damage.
1 Congenital hypothyroidism does not become
myxedema. 2 Thyrotoxicosis is another term for
nu
hyperthyroidism; it is not expected, but it can occur with
an overdose of exogenous thyroid hormone; it is too soon
l_
to discuss this with the parents. 3 This occurs only if
the infant has cerebral palsy.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
ca
Reference: Ch 30, Hypothyroidism, Data Base
67. 2 Diaper dermatitis is caused by prolonged repetitive
contact with an irritant (e.g., urine, feces, soaps,
detergents, ointments, and friction).
i
1 Both cloth and disposable diapers can cause diaper
in
dermatitis if not changed frequently. 3 An increased pH
or alkaline urine can contribute to diaper dermatitis.
4 A change in diet may contribute, but there is no
evidence that this is directly related.
cl
Client Need: Basic Care and Comfort; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Diarrhea,
@
Data Base
68. 1 Chalasia allows a reflux of gastric contents into the
esophagus and eventual regurgitation. Placing the
infant in an upright position keeps the gastric
contents in the stomach by gravity and limits the
pressure against the cardiac sphincter.
2 This probably will have little effect on chalasia. 3 This
will promote regurgitation; it is an unsafe position
because of the danger of SIDS. 4 This will promote
vomiting; the infant should be allowed to stop feeding
when satiated, not when the bottle is empty.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Nasopharyngeal and Tracheoesophageal Anomalies, Nursing Care
69. 4 Offering a new food after giving some formula
associates this activity with eating and takes
advantage of the infant’s unsatisfied hunger.
1 Solid food should be introduced by spoon to acquaint
the infant with new tastes and textures, as well as the use
of the spoon. 2 Offering food after the regular feeding
decreases the chance of success because the infant’s
hunger is already satisfied. 3 New foods should be
initiated one at a time and continued for 4 to 5 days to
assess for an allergic reaction.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Nutrition during Infancy, Guidelines for Infant Nutrition
g
70. 1 Crying should be prevented because it places
tension on the suture line. A metal appliance or
in
adhesive strips are secured to the cheeks to keep
the operative site relaxed, which helps prevent
trauma.
2 The infant may be positioned on the side and on the
back with surveillance. 3 This is not necessary or
desirable. 4 The feeding method of choice is by a
rubber-tipped syringe or dropper.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Cleft Lip and Cleft Palate, Nursing Care
71. 4 Infants with a cleft lip breathe through their
mouths, bypassing the natural humidification
provided by the nose. As a result, the mucous
membranes become dry and cracked and are easily
infected.
1 The area can be kept clean by washing with water after
each feeding. 2 Circulation in the area is unimpaired.
3 Feeding can be adequate with special equipment and a
patient approach.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Cleft Lip and Cleft Palate, Data Base
72. 4 Because the infant with a cleft lip and palate is
unable to form the vacuum needed for sucking,
a rubber-tipped syringe or dropper is used. This
allows formula to flow along the sides to the
back of the mouth, minimizing the danger of
aspiration.
1 A spoon is ineffective because the infant’s extrusion
reflex will prevent fluid from entering the mouth. 2 A
cross-cut nipple may be used with some infants, but a
rapid flow is dangerous because it can cause aspiration.
3 Feeding can be accomplished with special equipment;
IV fluids are not necessary.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Cleft Lip and Cleft Palate, Data Base
73. 4 A child with a cleft palate has distinctive speech
because the airflow required for speech cannot be
controlled; although speech therapy usually is
needed after surgery, surgery is scheduled before
the child starts to speak because correct speech is
easier to achieve.

1 This is not the reason the surgery is done at this
age. 2 Children with a cleft palate require orthodontic
and prosthodontic treatment for many years because of
the malformed palate and the malposition of the teeth;
the eruption of the teeth may be considered relative to
the timing of surgery throughout childhood, but the
2-year molars are of little importance when considering
the overall problem. 3 Although this may be true, this is
not the reason why the repair is made at this age; these
children may need multiple surgeries as the palate
develops.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Cleft Lip
and Cleft Palate, Data Base
74. Answer: 2, 1, 4, 5, 3.
2 These infants frequently have difficulty swallowing
secretions as well as difficulty breathing after surgery.
Nursing measures, such as placing the infant in a partial
side-lying position or gently aspirating secretions from
rs
the mouth or nasopharynx, may be necessary to prevent
aspiration and respiratory complications. 1 Vomiting
may compromise the airway and should be
monitored to ensure that excessive fluids are not
nu
prevented. 4 Infants have a delicate fluid and electrolyte
balance; parenteral fluid administration should be
administered. These children are transitioned to oral
fluids quickly. 5 This eventually will be done after the
l_
initial safety needs of the infant are met and the infant is
ready for oral fluids. 3 Of the interventions listed, this
is the least important in relation to the infant’s
ca
immediate needs postoperatively.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Cleft Lip and Cleft Palate, Nursing Care
75. 3 The olive-like mass is caused by the thickened
i
muscle (hypertrophy) of the pyloric sphincter.
in
1 The obstruction is above the intestinal area; the colon
is not involved. 2 There is no significant tenderness in
the abdomen. 4 There is little or no peristalsis in the
cl
intestines.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Hypertrophic Pyloric Stenosis, Data Base
@
76. 2 Hypertrophy of the pyloric sphincter (HPS) causes
partial and then complete obstruction.
Nonprojectile vomiting progresses to projectile
vomiting, which rapidly leads to dehydration.
1 The infant’s cry is not affected by HPS; there does not
appear to be pain associated with this condition, except
for the pain of hunger. 3 This can be expected with a
tracheoesophageal fistula, but not with HPS. 4 The
characteristics of the stool are not relevant when assessing
an infant with HPS.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Hypertrophic Pyloric Stenosis, Nursing Care
77. 3 Initial feedings of glucose and electrolytes in water
or breast milk are given 4 to 6 hours after surgery.
Answers and Rationales 743
When clear fluids are retained, formula feedings are
CHILD HEALTH NURSING
begun within 24 hours.
1 This is not necessary. Regular formula should be
started within 24 hours after surgery in an attempt to
gradually return the infant to a full feeding schedule. 2,
4 This is not necessary.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Hypertrophic Pyloric Stenosis, Nursing Care
78. 3 Assessment of the IV site is a priority. The infant will
need IV fluids until able to feed orally.
ANSWERS AND RATIONALES
1 Restraints are not needed. 2, 4 This is not the priority
action.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
g
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Hypertrophic Pyloric Stenosis, Nursing Care
in
79. 2 An elevated position allows gravity to aid in
preventing vomiting.
1 Movement increases the chance of vomiting. 3 This
will not prevent reflux and may result in
aspiration. 4 Activity increases the chance of vomiting.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Hypertrophic Pyloric Stenosis, Nursing Care
80. 2 Human milk has a laxative effect that promotes a
soft stool; breastfed infants rarely become
constipated.
1 There are no data to indicate that this infant has an
allergy to milk. 3, 4 This is unnecessary.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Anorectal
Anomalies, Data Base
81. 4 Because phenylalanine is an essential amino acid,
it must be provided in quantities sufficient for
promoting growth while maintaining safe blood
levels.
1 Phenylalanine is derived from protein, not fat. 2 An
enriched protein diet contains increased amount of
proteins, including phenylalanine, which should be
ingested in limited amounts. 3 Phenylalanine is an
essential amino acid and cannot be totally removed from
the diet.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Phenylketonuria (PKU), Data Base
82. 1 In phenylketonuria, the absence of the hepatic
enzyme phenylalanine hydroxylase prevents
metabolism (hydroxylation to tyrosine) of the
amino acid phenylalanine. The increased fluid levels
of phenylalanine in the body and the alternate
metabolic by-products (phenylketones) are
associated with severe mental retardation if not
identified and treated early.
2 Testing for PKU cannot be done until after several
days of milk ingestion. 3 Medications are not part of
therapy for PKU. 4 PKU is transmitted by an
autosomal recessive gene.
 744 CHAPTER 35 Child Health Nursing
Client Need: Physiological Adaptation; Cognitive Level:
CHILD HEALTH NURSING
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Phenylketonuria, Data Base
83. 4 To achieve optimal metabolic control, it is
recommended that people with classic
phenylketonuria (PKU) remain on a low-
phenylalanine diet for life.
1, 2 The nurse should respond truthfully and provide
clients with up-to-date information; dietary restrictions
are recommended for life. 3 This is no longer
ANSWERS AND RATIONALES
recommended; dietary restrictions are recommended for
life.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30,
Phenylketonuria, Data Base
84. 2 Obesity is a common nutritional problem of
children with Down syndrome. It is thought to be
related to excessive caloric intake and impaired
rs
growth.
1 This is a nutritional disorder related to vitamin
D deficiency; it usually is not encountered in these
children. 3 This is the most common nutritional
problem in children with an iron deficiency. 4 This
is an eating disorder of infancy characterized by
repeated regurgitation without a gastrointestinal
illness.
nu
l_
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Trisomy 21, Data Base
85. Answer: 3, 5.
ca
1 Weak pulse is unrelated to intestinal obstruction.
2 Hypotonicity is unrelated to intestinal obstruction.
3 Paroxysmal pain is related to the peristaltic action
associated with intestinal obstruction. 4 A high-pitched
i
cry is unrelated to intestinal obstruction; it is related to
in
neurological problems. 5 Abdominal distention pushes
the diaphragm upward, causing respiratory distress
characterized by grunting respirations.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
cl
Nursing Process: Assessment/Analysis; Reference: Ch 30,
Intestinal Obstruction, Data Base
86. 2 The traditional efforts to explain and treat colic
@
center on the paroxysmal abdominal pain; multiple
factors appear to be involved, such as immaturity of
the intestinal nervous system and lack of normal
intestinal flora.
1 Peristalsis is effective because these infants thrive
physically and gain weight. 3, 4 The etiology of colic is
unknown at this time.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 30, Colic, Data Base
87. 2 A full thickness rectal biopsy removes some rectal
tissue, which is examined microscopically for the
absence of ganglion cells.
1 A colonoscopy is not necessary to obtain a rectal
biopsy. 3 Saline enemas may relieve the obstruction, but
they are not a definitive diagnostic tool; a barium enema
may be used for diagnosis after the age of 2 months.
4 This is not used to diagnose the cause of an intestinal
obstruction in infants.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Hirschsprung Disease, Data Base
88. 2 Tap water enemas are hypotonic and are
contraindicated; they may cause increased
absorption of fluid via the bowel and may upset the
balance of fluid in the body. There also is
interference with potassium ion balance; this
electrolyte can be lost via the large intestine.
1 The enema removes waste products from the bowel,
g
not nutrients. 3 Fear of intrusive procedures is typical of
preschoolers, not infants. 4 The temperature of the
in
water is regulated, so this is not a concern.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 30, Hirschsprung Disease, Data Base
89. 3 Unless ordered, no more than 360 mL of solution
should be administered to a young child because
fluid and electrolyte balance in infants and children
is easily disturbed.
1 This quantity may be ordered for a small
infant. 2 This quantity may be ordered for an older or
larger infant. 4 This quantity is too much for a toddler.
Client Need: Basic Care and Comfort; Cognitive Level:
Knowledge; Nursing Process: Planning/Implementation;
Reference: Ch 30, Hirschsprung Disease, Data Base
90. 4 If the circulation is overloaded with too much fluid
or the rate is too rapid, the stress on the heart
becomes too great and cardiac overload may occur.
1 Increased output is not the primary concern.
2 Although fluid replacement is important, prevention
of cardiac problems from fluid overload is critical.
3 This is important, but an infiltrated IV is not as
serious as a cardiac complication.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 30, Diarrhea, Nursing Care
91. 2 Weight is the best indicator of fluid loss or gain if
measured each day at the same time, on the same
scale, and with the same amount of clothing;
1 liter of fluid weighs 2.2 pounds.
1 Oral rehydration therapy (ORT) is employed first; IV
therapy is instituted only if there is severe
dehydration. 3 Nutrition is not a concern at this
time. 4 Although important, this is not the priority.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 30, Diarrhea, Nursing Care
92. 2 Excessive vomiting causes an increased loss of
hydrogen ions (hydrochloric acid), which leads
to metabolic alkalosis, an excess of base
bicarbonate.
1 Acidosis is caused by retention of hydrogen ions and a
loss of base bicarbonate, which is more likely to occur
with diarrhea. 3 Hypokalemia, not hyperkalemia, will

occur. 4 With the loss of chloride ions, hyponatremia is
more likely to occur.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Vomiting, Data Base
93. 1 An infant’s intravascular compartment is limited
and cannot accommodate a large volume of fluid
administered in a short time. Equipment such as an
infusion pump with a volume-control chamber
should be used because it controls the prescribed
amount of fluid to be infused.
2 IV fluids for an infant are administered via an infusion
pump, not through intravenous tubing via gravity.
3 This is the health care provider’s role. 4 IV fluids are
administered at room temperature.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Diarrhea, Nursing Care
94. 4 The average respiratory rate for infants is 35
breaths/min. Tachypnea requires further
rs
investigation.
1 This temperature is within the expected range for
infants. 2 This blood pressure is within the expected
nu
range for infants. 3 This heart rate is within the
expected range for infants.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 30, Cardiac
l_
Malformations, Data Base
95. 3 Heart failure is characterized by a decrease in the
blood flow to the kidneys, causing sodium and
water reabsorption, resulting in peripheral edema.
ca
The peripheral edema indicates severe cardiac
decompensation.
1, 2 This is an early attempt by the body to
compensate for decreased cardiac output. 4 This
i
occurs most noticeably in children with acute post
in
streptococcal glomerulonephritis (APSGN), not heart
failure.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30, Cardiac
cl
Malformations, Data Base
96. 3 Children with cardiac malformations often require
more energy to achieve the activities of daily living;
@
decreased oxygen utilization and increased energy
output in the developing child result in a slow
growth rate.
1 Mental retardation is not a common finding in
children with congenital heart disease. 2 Cardiac
anomalies are more often a result of prenatal, rather than
genetic, factors. 4 Clubbing is not characteristic of most
children with cardiac anomalies, only of those with more
severe hypoxia.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 30, Cardiac Malformations, Data Base
97. 3 Polycythemia, reflected in an elevated hematocrit,
is a direct attempt of the body to compensate for
the decrease in oxygen to all body cells caused by
Answers and Rationales 745
the mixture of oxygenated and deoxygenated
CHILD HEALTH NURSING
circulating blood.
1 This is not characteristic of heart malformations that
cause a right-to-left shunting of blood. 2 Edema is not a
common finding with heart malformations associated
with a right-to-left shunting of blood. 4 This is
characteristic of coarctation of the aorta, an obstructive
malformation.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
ANSWERS AND RATIONALES
Ch 30, Cardiac Malformations, Data Base
98. 2 The intrapleural space must be drained of fluid and
air to facilitate the reestablishment of negative
pressure in the intrapleural space.
g
1 The tidal volume increases as the lung reexpands, but
it is not the reason for the insertion of chest tubes.
in
3 Intrapleural pressure should be negative, not positive;
positive intrapleural pressure causes collapse of the
lung. 4 Closed chest drainage is related to intrapleural
pressure, not pericardial and chest wall pressure.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Cardiac
Malformations, General Nursing Care of Children with Cardiac
Malformations
99. 4 Before birth, fetal oxygenated blood is shunted
directly into the systemic circulation via the
ductus arteriosus, a connection between the
pulmonary artery and the aorta. After birth,
the increased oxygen tension causes a functional
closure of the ductus arteriosus. Occasionally,
particularly in preterm infants, this vessel
remains open and is known as patent ductus
arteriosus.
1 This is not the problem in patent ductus arteriosus.
2 This describes a ventricular septal defect. 3 This
describes pulmonic stenosis.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 30, Defects with Increased Pulmonary Blood Flow,
Patent Ductus Arteriosus (PDA)
100. 4 With a left-to-right shunt, blood flows through a
defect in the ventricular wall of the heart and is
shunted from the higher-pressure left side to the
lower-pressure right side. The increased blood flow
from the right ventricle results in an increased
blood flow to the lungs.
1 Polycythemia and an increased hematocrit are not
common in children with a left-to-right shunt. 2 This is
not common in children with a left-to-right shunt.
3 Clubbing is a more common finding in children with
a right-to-left shunt.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 30, Cardiac Malformations, Data Base
101. 4 Coarctation of the aorta is a narrowing of the aorta,
usually in the thoracic segment, causing decreased
blood flow below the constriction and increased
blood volume above it.
 746 CHAPTER 35 Child Health Nursing
1 The radial pulses are bounding. 2 This is not related
CHILD HEALTH NURSING
to coarctation of the aorta. 3 The femoral pulses are
weak or absent.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Obstructive Defects, Coarctation of the Aorta
102. 3 Compromised heart functioning causes decreased
cardiac output; this often results in cyanosis
and fatigue from ineffective sucking and
swallowing.
ANSWERS AND RATIONALES
1 When a feeding problem persists in a neonate,
it generally is an indication of some pathology.
2 Inadequate sucking is never insignificant; it may be
indicative of many problems, such as central nervous
system involvement or immaturity as well as heart
disease. 4 Healthy newborns are free from mucus within
24 to 48 hours after birth.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 30,
rs
Defects with Increased Pulmonary Blood Flow, Ventricular Septal
Defect (VSD)
103. 2 Hemorrhage is a major life-threatening complication
because arterial blood is under pressure and a
catheter has been inserted into an artery.
1 The child is kept in bed for 6 to 8 hours after an
nu
arterial catheterization. 3 Fluids may be given as soon as
tolerated. 4 Pulses, not blood pressure, must be
l_
compared for quality and symmetry.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Cardiac Malformations, General Nursing Care of
ca
Children with Cardiac Malformations
104. 3 Circumoral cyanosis is not a specific characteristic
of Down syndrome. It is a clinical finding associated
with congenital heart disease, which these infants
i
may have as a concurrent problem.
in
1 A flat occiput and a broad nose with a depressed
bridge (saddle nose) are head and facial features of
children with Down syndrome. 2 Small, misshapen,
low-set ears are a clinical manifestation of Down
cl
syndrome. 4 Children with Down syndrome often keep
their mouths open and their tongue protrudes; the
surface of the tongue is often wrinkled.
@
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 30, Trisomy 21, Data Base
105. 3 Tetralogy of Fallot consists of four defects. Three of
them are anatomic: ventricular septal defect,
pulmonic stenosis, and overriding aorta. The fourth
defect, right ventricular hypertrophy, is secondary
to increased resistance to blood flow in that
ventricle.
1, 4 Although there is right ventricular hypertrophy, the
other defects are not associated with tetralogy of Fallot.
2 These are the characteristics of transposition of the
great vessels.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Defects with Decreased Pulmonary Blood Flow,
Tetralogy of Fallot
106. 2 Decreased tissue oxygenation stimulates
erythropoiesis, resulting in excessive production
RBCs.
1, 4 This is not a direct cause of polycythemia. 3 This
may or may not affect the production of RBCs.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Defects with Decreased Pulmonary Blood Flow,
Tetralogy of Fallot
107. 2 Hypoxia leads to poor peripheral oxygenation of
tissues; clubbing develops over time as a result
of tissue hypertrophy and additional capillary
g
development in the fingers.
1 The respirations generally are rapid to compensate for
in
oxygen deprivation. 3 These children have
polycythemia. 4 These do not occur in children with
tetralogy of Fallot.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 30, Defects with Decreased Pulmonary Blood Flow, Tetralogy of
Fallot
108. 3 Forceful evacuation results in taking a deep breath,
holding it, and straining (Valsalva maneuver). This
increases intrathoracic pressure, which puts
excessive strain on the heart sutures.
1 Crying is not a problem after cardiac surgery; it may,
in fact, help prevent respiratory complications.
2 Coughing and deep breathing are essential for the
prevention of postoperative respiratory complications.
4 Activity is gradually increased.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Cardiac Malformations, Data Base
109. 2 This is a priority because inadequate antibiotic
therapy may predispose the infant to the
development of bacterial endocarditis.
1, 3, 4 This is not a priority because instructions usually
are printed on the label.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Cardiac Malformations, Data Base
110. 3 Gavage feeding is preferred for weak infants, those
with respiratory distress or ineffective sucking-
swallowing coordination, and those who are easily
fatigued. It conserves energy and reduces the
workload of the heart.
1 This is not a reason for instituting gavage feedings;
however, vomiting may be lessened because the amount
and rapidity of the feeding can be controlled. 2 Feeding
the infant quickly is not desirable; vomiting with
aspiration may occur. 4 The amount can be regulated
with oral formula feeding as well.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Assessment/Analysis; Reference: Ch 30, Cardiac
Malformations, Data Base

111. 3 Antibodies received in utero through the placenta
and in the newborn via the mother’s breast milk
provide the infant with immunity against most
viral, bacterial, and fungal infections during the
first several weeks after birth. Then, as the titer of
maternal antibodies drops and is not replaced by
the infant’s own antibodies, prolonged and
repeated infections occur.
1 This is not enough to prevent infections in these
infants. 2 Bacteria do not produce antibodies. 4 This
probably does not occur in infants born without an
immune system.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis,
Reference: Ch 30, Immunizations
112. 2 This is the expected hematocrit range for a 1-year-
old infant.
1 This is too low; it occurs with problems such as
prolonged blood loss. 3 This is too high; this is the
expected hematocrit for an adult female. 4 This is too
rs
high; this is the expected hematocrit for a newborn.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Assessment/Analysis;
nu
Reference: Ch 30, Growth and Development, Ten to Twelve Months
113. 2 Toxoids are modified toxins that stimulate the body
to form antibodies that last up to 10 years against
the specific disease.
1 Passive immunity, even the natural type derived from
l_
the mother, does not last longer than the first year of
life. 3 Only having had the disease can provide lifelong
natural immunity. 4 This is provided by tetanus
ca
immune globulin.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Immunizations
i
114. Answer: 2, 4, 5.
in
1 Rubeola (measles) vaccine is made from a live
attenuated virus. 2 Pertussis (whooping cough) vaccine
is made from inactivated toxins. 3 Varicella (chicken
pox) vaccine is made from a live attenuated virus. 4 It is
cl
safe to receive the inactivated poliovirus vaccine; it is not
a live attenuated virus vaccine. 5 Tetanus immune
globulin is an antitoxin that provides transient passive
@
immunity; tetanus toxoid is contraindicated.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 30, Immunizations
115. 1 Varicella (chickenpox) is caused by a virus and may
be followed by encephalitis. It is characterized by
skin lesions.
2 Scarlet fever is caused by a bacterium and does not
result in encephalitis. 3 Although poliomyelitis is
caused by a virus, it does not result in encephalitis.
4 Whooping cough (pertussis) is caused by a bacterium
and does not result in encephalitis.
Client Need: Physiological Adaptation; Cognitive Level: Knowledge;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 30, Immunizations
Answers and Rationales 747
116. 1 The signs and symptoms of rubeola (measles)
CHILD HEALTH NURSING
include a high fever, photophobia, Koplik
spots (white patches on mucous membranes
of the oral cavity), and a rash. Rubella (German
measles) usually does not cause a high fever,
runs a 3- to 6-day course, and never causes Koplik
spots.
2 The rash of rubeola (measles) spreads over most of the
body. 3 These clinical findings are vague and occur with
many illnesses. 4 Some signs and symptoms may be
ANSWERS AND RATIONALES
similar to those of a severe cold, but rubeola is associated
with high fever.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
g
Process: Planning/Implementation; Reference: Ch 30,
Immunizations
in
117. 1 The American Academy of Pediatrics and the
Centers for Disease Control and Prevention are not
recommending the IM polio vaccine because of the
danger of acquiring vaccine-associated polio
paralysis (VAPP) with the oral vaccine.
2 Both vaccines are not equally safe; the intramuscular
one is safer. 3 Cost is not the issue; safety is. The
oral vaccine is less expensive. 4 If the infant is
immunocompromised, the health care provider will
discuss with the parents whether the vaccine should be
administered.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Immunizations
118. 2 Steroids have an immunosuppressive effect. It is
thought that resistance to certain viral diseases,
including varicella, is greatly decreased when a
child takes steroids regularly.
1 There is no known correlation between varicella and
insulin. 3 Because varicella is a viral disease, antibiotics
will have no effect. 4 There is no known correlation
between varicella and anticonvulsants.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Immunizations
119. 3 Varicella (chickenpox) begins with a slight fever,
malaise, and anorexia. After 24 hours a highly
pruritic rash begins with a macule, progressing to
papules, and then vesicles that break easily. The
rash spreads in a centripetal manner from the trunk
to the face and proximal extremities. Secondary
bacterial complications (e.g., encephalitis,
pneumonia, and hemorrhagic varicella) are
potential complications.
1 This is a benign childhood communicable disease;
complications are rare; women of childbearing age should
be vaccinated because rubella, if contracted in early
pregnancy, can cause congenital anomalies in the
newborn. 2 Rubeola (measles) produces coldlike
respiratory symptoms and, after 3 or 4 days, a dark-red
macular or maculopapular skin rash. 4 Scarlet fever is a
 748 CHAPTER 35 Child Health Nursing
bacterial infection that responds to antibiotic therapy and
CHILD HEALTH NURSING
does not cause major complications.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 30, Immunizations
120. 4 Scheduled immunizations for preschool children
include DTaP, IPV, and MMR at 4 to 6 years (usually
required by law).
1 Hepatitis immunization is given in three doses
between birth and 9 months; tetanus/diphtheria vaccine
ANSWERS AND RATIONALES
is given at 7 to 10 years of age, with subsequent doses
based on the age when the vaccine was first received.
2 Hepatitis B immunization is not required once
immunity is established; a subsequent dose of tetanus/
diphtheria vaccine is given based on the age when first
received. 3 Haemophilus influenzae vaccine is given at 12
to 15 months.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
rs
Immunizations
121. 2 The recommended immunization schedule for
infants is administration of the combined
and 6 months.
nu
diphtheria, tetanus, acellular pertussis (DTaP), and
inactivated poliovirus (IPV) vaccines at ages 2, 4,
1 Measles vaccine is not usually administered until the
infant is a minimum of 12 months old. 3 Rubella
l_
vaccine is not usually administered until a minimum of
12 months of age; there is no tuberculosis vaccine.
4 Measles, mumps, and rubella vaccines are not given
until a minimum of 12 months; there is no tuberculosis
ca
vaccine.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Evaluation/Outcomes,
Reference: Ch 30, Immunizations
i
122. 2 The protocol of the Centers for Disease Control and
in
Prevention (CDC) for administering parenteral
medications requires standard precautions, which
include the use of gloves.
1 It is the nurse’s responsibility to maintain standard
cl
precautions within the clinic environment. 3 Gloves are
needed and must be worn when children receive
parenteral medications. 4 The child’s appearance is not a
@
factor; the CDC protocol for administering parenteral
medications requires standard precautions.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 29, Principles
Related to Medications for Children, Nursing Care
123. 2 The MMR vaccine is composed of live attenuated
viruses, and its administration could be
life-threatening for an immunosuppressed
child.
1 When the infant reaches 12 to 15 months of age and
if the blood values have returned to normal, the MMR
vaccine should be given. 3 Because the MMR vaccine is
composed of live viruses, giving it while the infant is
immunosuppressed can be as life-threatening as having
the disease. 4 It is the nurse’s responsibility to provide
this information at the time of discharge.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Immunization
124. 1 The blue-white spots in the mouth are Koplik spots,
which appear before the rash and subside
about 2 days after the rash is visible. They are a
cardinal sign of rubeola (measles).
2 The rash of varicella (chickenpox) is distinctive because
the papules become vesicles. There are no Koplik
spots. 3 Erythema infectiosum (fifth disease) has a
characteristic erythematous rash that appears first on the
g
face and then spreads to the extremities. There are no
Koplik spots. 4 Scarlet fever is caused by group A
in
beta-hemolytic streptococcus bacteria. Although the
mouth is affected, as evidenced by the typical “strawberry
tongue,” there are no Koplik spots.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30,
Immunizations
Care of Toddlers
125. Answer: 9.5 mg. Since there are 2.2 pounds per
kilogram, the child’s weight of 28 lb is equal to
12.7 kg. The safe dose is determined by multiplying
the child’s weight in kilograms by 35 (12.7 × 35),
which is 444.5 mg/24 hours. To calculate the child’s
dose in 24 hours, multiply the prescribed dose
(145 mg) by 3, which equals 435 mg in 24 hours.
Subtract 435 from 444.5, which equals 9.5 mg.
Because the daily dose is 9.5 mg less than the
maximum safe daily dose of 444.5 mg, it is safe to
administer this amount of medication.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 29, Principles Related to Medications for Children,
Nursing Care
126. 4 A specific dose per kilogram of body weight
prevents overdose; there is a large range in weight
for specific ages, and a uniform dose based on age
could be unsafe or ineffective.
1 This may result in an inadequate dose. 2 Medication
is important; the child has a fever. 3 This is unsafe
because of the wide range of weights for a specific age
group.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 29,
Principles Related to Medications for Children, Nursing Care
127. 2 When unexplained injuries are found, further
assessment is required because it is the nurse’s
legal responsibility to report suspected child abuse.
1 This is just one aspect of assessment for child abuse.
3 This is not related to scars on the child’s back. 4
Although chickenpox may leave scars, there are no welts.

Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Assessment/Analysis; Reference: Ch 31, Child
Maltreatment, Nursing Care
128. 2 The nurse should obtain clarification as to the
parent’s specific concerns regarding the child’s
behavior.
1 Although this may be true, it cuts off communication;
further communication should be encouraged. 3 This
response assumes the parents have been inconsistent; the
nurse needs more information. 4 This is inappropriate
because the nurse is explaining a developmental factor
without exploring what the parent means.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 31, Growth and Development, Developmental
Timetable
129. 3 It is the nurse’s legal responsibility to report child
abuse to the appropriate agency.
rs
1 Although the police may be notified, this is not the
nurse’s responsibility at this time. 2 This may be done
later, but it is not the priority. 4 The girl’s pregnancy
has not been confirmed; at this time it is most important
to protect her and her sisters.
nu
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 31, Child
l_
Maltreatment, Data Base
130. 4 A child who exhibits signs of abuse needs close
supervision, especially when members of the family
visit.
ca
1 The child needs close monitoring and should not be
left alone. 2 An older child who exhibits signs of
friendliness may be threatening to this child. 3 This may
be desirable from a developmental level, but it does not
i
meet the child’s safety needs.
in
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 31, Child Maltreatment, Nursing
Care
cl
131. 2 If able to handle personal anxiety and give comfort
to the toddler, parents can be helpful to the staff as
well as the child. If, however, the parents have
moderate to severe anxiety, their anxiety can be
@
transmitted to the child.
1 It is how the parents cope with the situation, rather
than the situation itself, that helps determine how helpful
their presence may be. 3 Developmentally, toddlers fear
separation from their parents; also they are cognitively
unable to make decisions of this nature. 4 Parents
usually want to participate in their child’s care despite the
child’s response to pain.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Assessment/
Analysis; Reference: Ch 31, Hospitalization of Toddlers, General
Nursing Care of Toddlers
132. 4 A 2-year-old toddler is still attached to and
dependent on the parents. Fear of separation is a
great stress.
Answers and Rationales 749
1 This is neither possible nor desirable. 2 This probably
CHILD HEALTH NURSING
will not be remembered accurately. 3 This is not
possible in a health care setting.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 31,
Hospitalization of Toddlers, General Nursing Care of Toddlers
133. 2 The second stage of separation anxiety is despair,
in which the child is depressed, lonely, and
disinterested in the surroundings.
1 The third stage of separation, denial or detachment,
ANSWERS AND RATIONALES
occurs later as hospitalization becomes prolonged. 3 The
child is suffering from separation anxiety, which does not
include a stage of mistrust. 4 The child is suffering from
g
separation anxiety, which does not include a stage of
rejection.
in
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 31, Hospitalization of Toddlers, Data Base
134. 1 Superficial interest in the environment and friendly
interactions with strangers are typical responses of a
toddler who has experienced prolonged separation
from parents because of illness. It is the third stage
of separation anxiety known as detachment.
2, 4 This behavior is typical of the second stage of
separation anxiety known as despair. 3 This behavior is
typical of the first stage of separation anxiety known as
protest.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 31, Hospitalization of Toddlers, Data Base
135. 1 Detachment is the result of trying to escape the
emotional pain of desiring the mother by
repressing feelings for her.
2 This interpretation is not appropriate to the
situation. 3 This conclusion cannot be drawn from this
situation. 4 This response lacks insight.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 31, Hospitalization of Toddlers, Data Base
136. Answer: 1, 2, 3.
1 Toddlers are entering the developmental stage of
creative and imaginative play. Having an imaginary tea
party is a safe, appropriate activity for a toddler. 2 Using
clay to make shapes, both with and without a mold,
enhances toddlers’ creativity and improves their fine
motor coordination. 3 Creative, imaginative, and
imitative play is associated with toddlers. 4 A 3-year-old
child is too young to manipulate a pen or pencil and
may cause self-injury or an injury to others. 5 A 3-year-
old child does not have the cognitive ability or the fine
motor coordination to play simple video games.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Caring; Nursing Process:
Planning/Implementation; Reference: Ch 31, Play during
Toddlerhood
137. 1 The medicine cabinet is not a safe place for
medications; toddlers are curious, and capable of
climbing and opening cabinets.
 750 CHAPTER 35 Child Health Nursing
2 Toddlers are curious and love to climb. They must be
CHILD HEALTH NURSING
protected from dangerous areas such as stairs. Secured
gates at the top and bottom of stairs provide a barrier.
3 At a height of 36 inches a toddler is ready to use a
bed; the average toddler reaches this height at age 2 1 2
years. 4 Shoes with Velcro can be secured without
leaving trailing shoelaces that can untie and cause falls.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 31, Health
ANSWERS AND RATIONALES
Promotion of Toddlers, Injury Prevention during Toddlerhood
138. Answer: 3, 1, 4, 2, 5.
3 A compromised airway may occur with burns to the
face and chest due to inhalation of hot gases and smoke;
they cause mucosal damage and edema. 1 Deep partial
thickness burns are painful; pain management is a
priority after maintenance of a patent airway and
promotion of gas exchange. 4 Because of the fluid and
electrolyte losses within the first 24 to 36 hours and the
resulting shift of electrolytes after the first 24 to 36
rs
hours, fluid and electrolyte balance become a priority
after airway maintenance and pain management.
2 Prevention of infection becomes a priority after airway
maintenance, pain management, and maintenance of
nu
fluid and electrolyte balance; the potential for infection
increases as the postinjury time frame progresses because
of the damaged dermis. 5 Body image becomes more of
a priority after immediate physiological needs are met.
l_
Client Need: Management of Care; Cognitive Level: Analysis;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 31, Burns,
Nursing Care
ca
139. 2 The poison control center has the most current and
up-to-date information on how to treat any poison.
Also, the center can advise whether to bring the
child to the hospital and what data to collect to
i
bring with them if they go to the hospital.
in
1 The administration of syrup of ipecac is no longer
recommended by the American Academy of Pediatrics. It
is contraindicated if the ingested poison is a corrosive
substance or a hydrocarbon; also, it is contraindicated if
cl
the child is comatose or having seizures. In addition,
prescribing medication is outside the legal role of the
nurse. 3 A potential poisoning may or may not require
@
emergency intervention; with expert advice the child may
be treated in the home. Also, the experts at the poison
control center can provide advice about initial
interventions at home before going to the hospital.
4 This is unsafe. No treatment should begin before
obtaining information about the amount and kind of
substance ingested and the advice of a health care
provider.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 31, Poisoning,
Nursing Care
140. Answer: 2, 4, 5.
1 At 15 months, children do not have the emotional
ability to share toys; this begins during the preschool
years. 2 At 15 months, children have the dexterity and
swallowing ability to drink from a cup and use a spoon.
3 This ability usually occurs when the child is 2 years
old. 4 At 15 months, strength and balance have
improved, and the toddler can stand and walk alone.
5 At 15 months, children enjoy throwing objects and
picking them up.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Growth and Development, Fifteen Months
141. 2 The psychosocial need during the early toddler age
is the development of autonomy. The toddler
objects strongly to discipline.
1 Excessive discipline leads to feelings of shame and
g
self-doubt, the major crisis at this stage of development.
3 It is frightening for a toddler to be left alone; it
in
leaves the child with feelings of rejection, isolation, and
insecurity because toddlers do not understand the reason
for the punishment. 4 The development of initiative
is attained during the preschool age, not during the
toddler age.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Growth and Development, Eighteen Months
142. 1 Children who are expressing negativism need to
have a feeling of control. One way of achieving
this within reasonable limits is for the parent or
caregiver to provide a choice of two items, rather
than force one on the child.
2 This will not achieve the goal of giving fluids. 3 This
probably will not be successful with a toddler. 4 This
will complicate the situation and further inhibit the
child’s willingness to take fluids.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Childhood Nutrition
143. 3 The nurse should try to comfort the child by staying
near until the child feels more relaxed. The bathing
can be postponed until the child has had time to
test the environment and is less anxious.
1 This may frighten the child more because the nurse is
a stranger. 2 This action does not attempt to relieve the
child’s anxiety and will probably cause it to increase.
4 Basic physiological needs must be met and postponing
the bath for a day would be negligent. However, the
nurse should attempt to reduce the child’s anxiety first.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 31,
Hospitalization of Toddlers, General Nursing Care of Toddlers
144. 3 Appropriate limit setting and discipline are
necessary for children to develop self-control while
learning the boundaries of their abilities.
1 Learning to share occurs during the preschool
years. 2 Roles within society are learned by the
school-age child. 4 Internal controls begin in the
preschool years.

Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Growth and Development, Major Learning Events
145. Answer: 1, 2.
1 Common developmental norms of the toddler, who is
struggling for independence, are an inability to share
easily, egotism, egocentrism, and
possessiveness. 2 Toddlers have a basic understanding of
language and the cognitive ability to follow simple
directions. 3 This task is too advanced for toddlers.
4, 5 This is true of preschool-age children.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Growth and Development, Two Years
146. 2 The child should be taken to the dentist
between 2 and 3 years of age, when most of the
20 deciduous teeth have erupted.
1, 3 This is too late. 4 This is too indefinite.
Client Need: Health Promotion and Maintenance; Cognitive
rs
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Growth and Development, Thirty Months
147. 4 The toddler is in Erikson’s stage of acquiring a
the environment.
1 This is the developmental goal achieved in
nu
sense of autonomy. The negativism is the result of
the child’s need for self-expression and for testing
l_
infancy. 2 Although this is a factor, toddlers assert
themselves in an attempt to attain more autonomy.
3 Children do not assert themselves to obtain
discipline.
ca
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Growth and Development, Two Years
i
148. 2 Ignoring the tantrum while staying close by
provides security while not giving attention to and
in
reinforcing the behavior.
1 Although toddlers may be easily distracted, offering a
toy will reinforce the negative behavior. 3 It is
cl
unreasonable to tell the parent to find someone to
baby-sit the child; this may not be a viable
option. 4 Giving the child the item acknowledges the
@
tantrum and reinforces the behavior.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Hospitalization of Toddlers, General Nursing Care of Toddlers
149. 4 These are foods that a toddler enjoys and can
handle; in addition, they are nutritious.
1 Grapes are dangerous because toddlers may choke
on the skins and shape of the grape. 2 These fried
foods have a high fat content and if eaten regularly
can lead to obesity. 3 The skin and shape of a hot
dog may cause choking, and potato chips are not
nutritious.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Childhood Nutrition
Answers and Rationales 751
150. 3 Bed-wetting accidents are not uncommon in this
CHILD HEALTH NURSING
age group, especially during hospitalization when
regression may occur. Therefore, the best approach
is to ignore the event.
1 The child may interpret this as punishment;
punishment for regressive behavior is inappropriate.
2 Because skin breakdown is a concern, rubber sheets are
contraindicated; they hold moisture close to the
skin. 4 This may make the child feel guilty for the
behavior.
ANSWERS AND RATIONALES
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 31,
Hospitalization of Toddlers, General Nursing Care of Toddlers
g
151. 4 This is a task expected of 3-year-old children.
1 This is a task expected of 4- or 5-year-old children.
in
2, 3 This is a task expected of 4-year-old children.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Growth and Development, Thirty Months
152. Answer: 3, 5.
1 This is unsafe; a toddler may choke because of the
shape of the grape and its skin. 2 Cold food and fluids
may precipitate bronchospasms and should be avoided.
3 Apple slices are easy to handle and chew and provide
excellent nutrition for a toddler. 4 Cookies are high
in fat and sugar and are not as healthy as fruit.
5 Vegetables cut up into small pieces can be handled and
chewed effectively by a 2-year-old child; also, they are
nutritious and prevent constipation. 6 Cold fluid may
cause bronchospasms.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 31, Childhood Nutrition
153. 1 The toddler is still dependent on the primary care
giver, is narcissistic, and plays alone, but is aware of
others playing nearby.
2 Solitary play or onlookers’ play is characteristic of
infants. 3 Cooperative play starts in the preschool
years. 4 Competitive play is seen in school-age children.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Play during Toddlerhood
154. 3 It is not until 2 years of age that toddlers are able
to use their feet to walk upstairs instead of
crawling.
1 Talipes equinovarus is identified using other
criteria. 2 At 18 months of age the inability of the
toddler to use the feet to go upstairs is not a problem; it
is expected. 4 Developmental dysplasia of the hip
(DDH) is identified using other criteria.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Growth and Development, Eighteen Months
155. Answer: 3, 4.
1 An infant will enjoy a mobile. 2 This is too advanced
for a 2-year-old child. 3 A pounding toy allows for gross
motor movements as well as an avenue to expend energy
and feelings. 4 Clay (Play-Doh) is age-appropriate and
 752 CHAPTER 35 Child Health Nursing
nontoxic; manipulating, rolling, and pounding it may
CHILD HEALTH NURSING
help work out feelings about being hospitalized. 5 This
may be too complicated for a toddler.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Play during Toddlerhood
156. 2 More information is needed; developmental delays
suggest some milestones for age are not being met
at the average time; it is not synonymous with
cognitive impairment.
ANSWERS AND RATIONALES
1 This is inappropriate; more information must be
obtained. 3 Although the health care provider may help,
it is not yet known if such a program is needed. 4 The
nurse does not know this without more information.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 31, Cognitive Impairment, Nursing Care
157. 3 Echolalia in a 2-year-old child may be a sign of
autism; imitation of sounds begins at about 6
rs
months of age and may continue for several more
months. The average 2-year-old child has a 300-
word vocabulary and uses 2- to 3-word phrases.
nu
1 It is not until 30 months of age that the toddler is
able to stand on one foot. 2 Building a tower of 5 to 6
blocks is expected at the age of 2 years. 4 Although the
pincer grasp is achieved at 11 months, it is not until age
30 months that the toddler is expected to hold crayons
l_
with the fingers rather than the fists and be able to color
within the lines of a picture.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
ca
Reference: Ch 31, Growth and Development, Two Years
158. 1 The parents’ attitude, approach, and understanding
of the child’s physical and psychologic readiness are
essential to letting the child proceed at his or her
i
own pace with appropriate parental intervention.
in
2 This is not the major motivation for toilet training.
3 Although this is definitely a factor, it is not a major
one. 4 This, of course, is a factor, but the major factor is
the child, who is strongly influenced by the parents’
cl
attitudes and approach.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
@
Nursing Process: Assessment/Analysis; Reference: Ch 31, Growth
and Development, Major Learning Events
159. 4 A pounding board with pegs to hammer into holes
is a safe toy for toddlers because it is fairly large,
easy to manipulate, and sturdy. A pounding board
provides an acceptable way for anger to be
expressed.
1 The child’s motor and hand-eye coordination are too
immature for using these. 2 This is not as effective for
releasing anger; it may be thrown about, causing injury
or damage. 3 This is appropriate for an older child with
more mature motor coordination to compensate for a
moving object.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Hospitalization of Toddlers, General Nursing Care of Toddlers
160. 4 Until trust has been reestablished, the child will be
unable to develop an emotional tie to the mother.
1 After trust has been reestablished, the child may then
test the parent’s love by being very demanding. 2 At this
stage of separation anxiety, the child is too detached to
be hostile. 3 The child will be despairing and
withdrawn, not cheerful.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31,
Hospitalization of Toddlers, Data Base
161. 3 A 15-month-old toddler will have difficulty
g
complying with directions to remain still and may
be extremely frightened by the equipment.
in
Sedatives usually are prescribed.
1 This is not necessary; the head must remain still but
need not be shaved. 2 This is not necessary unless a
contrast medium is being used. 4 The child is too
young to understand even a simple explanation of the
procedure.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Hospitalization of Toddlers, General Nursing Care
of Toddlers
162. 2 Braces are worn to enable the spastic child to
control movement. They also prevent deformities
that can occur from misalignment.
1 Early ambulation is promoted by maintaining muscle
strength and tone, but it is not the reason for applying
braces. 3 Exercises, not braces, are used to stretch
ligaments and improve muscle strength and tone. 4 This
is not the purpose of braces and shoes. The child is in
Erikson’s stage of industry versus inferiority, and the
braces and shoes will promote independence.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Cerebral
Palsy, Nursing Care
163. 1 Individuals whose thermoreceptive senses are
impaired are unable to detect changes or degrees
of temperature. They must be taught to first test
the temperature in any water-related activity to
prevent scalding and burning.
2 Overtightening brace straps may lead to circulatory
impairment and/or skin breakdown. 3 The child with
cerebral palsy has uncontrolled movement of voluntary
muscles and does not need to change positions at night
to prevent skin breakdown. 4 This is dangerous because
this action alters the center of gravity; with practice the
child will be able to place the legs in the appropriate
position for walking without looking down.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Cerebral
Palsy, Nursing Care
164. 1 The damage is fixed. It does not progressively
worsen.

2 Cerebral palsy (CP) is a nonprogressive chronic
condition, and its effects are predictable. 3 Although
mental retardation may be present in some children with
cerebral palsy, all children with this disorder are not
mentally retarded. 4 A variety of prenatal, perinatal, and
postnatal factors contribute to the development of CP. It
is estimated that the cause of CP is unknown in as many
as 80% of people with the disorder.
Client Need: Physiological Adaptation; Cognitive Level:
Knowledge; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Cerebral Palsy, Data Base
165. 3 Lead poisoning is caused by lead in the
environment. Sources of lead may be deteriorating
paint in a home (inhaled or ingested); lead in
products that are used daily, such as batteries,
pottery, and glass (ingested); and lead in the
atmosphere (which can be inhaled or fall on food
that is then ingested).
1 Unless the fat has been exposed to lead, it is not a
causative factor. 2 The role of parents is not an
rs
identified factor. 4 This is just one causative factor; there
are many others.
Client Need: Health Promotion and Maintenance; Cognitive
166. 3 Damaged nerve cells do not regenerate. Once
nu
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Lead Poisoning, Data Base
mental retardation has occurred, it is not reversible.
1 Damage to kidneys is reversible with
l_
treatment. 2 Skeletal changes are not significant and are
reversible as lead leaves the body. 4 Effects of lead in
bone marrow are reversible when lead is mobilized for
ca
excretion in urine or deposition in bone by chelation
therapy.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Lead Poisoning, Data Base
i
167. 2 Irreversible neurologic and intellectual damages
in
are the most serious consequences of lead
poisoning because of cortical atrophy and
encephalopathy.
1 Although there may be a nutritional deficit, it is not
cl
the priority. 3, 4 These do occur, but they are reversible.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
@
31, Lead Poisoning, Data Base
168. 4 The child should be given an outlet for tension, and
therapeutic play using the equipment needed for
the injections is the most appropriate activity.
1 This may ease discomfort, but an outlet for feelings
takes priority. 2 Fear is not directed at unfamiliar adults
but at the painful treatments. 3 This is part of the
preparation, but it is not the most important; the child
must be encouraged to express feelings.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Lead Poisoning, Nursing Care
169. 4 Amblyopia is reduced visual acuity that may occur
when an eye weakened by strabismus is not forced
to function.
Answers and Rationales 753
1 The lack of binocularity may result in impaired depth
CHILD HEALTH NURSING
and spatial perceptions, not dyslexia. 2 Depth and
spatial perceptions are impaired when vision in one eye is
severely impaired. 3 Only vision in the affected eye will
be diminished.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Visual Impairment, Data Base
170. 4 In children younger than 3 years old the eustachian
tube is shorter, wider, and straighter. Pulling the
ANSWERS AND RATIONALES
pinna down and back straightens the ear canal
facilitating passage of fluid to the eardrum.
1 Pulling the pinna forward does not straighten the
g
canal. 2 Pulling the pinna up and back is the technique
used for older children and adults. 3 Pulling the pinna
in
straight back does not help to straighten the canal.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 29,
Principles Related to Medications for Children, Nursing Care
171. 4 If the strabismus is not corrected, sight in the
affected eye will be lost because of lack of use.
1 Cataracts do not result from strabismus. 2 Glaucoma
is caused by increased intraocular pressure, not
strabismus. 3 Refractive errors are related to visual
acuity rather than strabismus.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Visual Impairment, Data Base
172. 2 By 3 to 4 months of age, an infant should localize
sound by looking in the direction of the sound.
1 The nurse’s observation does not provide information
about the infant’s ability to see. 3 This response is not
within the norm for this age group. 4 This response
indicates that that the infant’s hearing is not
developmentally appropriate.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Hearing Impairment, Data Base
173. 2 Water in the ears after a myringotomy may be a
source of infection.
1 There is no reason that the child cannot be around
other children because there is no infectious
process. 3 This will clog the ear canal and serves no
purpose. 4 These may be used occasionally in the outer
ear but should not be inserted into the ear.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 30, Otitis
Media, Nursing Care
174. 4 This degree of hearing loss causes the child to miss
approximately 25% to 40% of conversations. This
loss may result in speech deficits if not corrected.
Hearing aids usually help improve functioning.
1 There is no evidence that this hearing loss is
progressive. 2 The child is missing approximately 25%
to 40% of conversations, which may interfere with the
 754 CHAPTER 35 Child Health Nursing
educational process unless corrected. 3 The significance
CHILD HEALTH NURSING
of the hearing loss requires further analysis and
intervention.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Hearing Impairment, Data Base
175. The posterior tibial artery is posterior to the medial
malleolus on the inner aspect of the ankle. The
blood pressure cuff should be positioned 1 inch
above the ankle.
ANSWERS AND RATIONALES
Client Need: Reduction of Risk Potential; Cognitive
Level: Analysis; Nursing Process: Planning/
Implementation; Reference: Ch 31, Fractures
throughout Childhood, Nursing Care
rs
Posterior
tibial
nu
l_
artery
176. 4 Abusive parents may “shop” for hospitals that
do not have a previous record of their child; the
ca
skeletal survey will provide a revealing injury
history if there were abuse.
1 Pinpointing the exact location of a fracture is necessary
to plan appropriate treatment and can be done by a
i
single x-ray film of the area; a skeletal survey is more
in
extensive and helpful when abuse is suspected. 2 A CT
scan and MRI are not required unless internal injuries
are suspected. 3 Cost-effectiveness is not the primary
concern if abuse is suspected.
cl
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Child Maltreatment, Nursing Care
@
177. Answer: 2, 4, 5.
1 This is not significant; it may be related to increased
fluid intake. 2 A cast is not flexible and can inhibit
circulation. Cold toes, loss of sensation in toes, pain, and
inability to move the toes should be reported immediately.
3 The expected pulse rate for a 9-year-old child ranges
from 70 to 110 beats/min. 4 A tingling sensation in the
foot may indicate excessive pressure on the nerves and
circulatory system in the casted extremity. 5 A fiberglass
cast dries within minutes; if it remains damp, it should be
reported before 4 hours have elapsed.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Communication/Documentation; Nursing
Process: Evaluation/Outcomes; Reference: Ch 31, Fractures
Throughout Childhood, Nursing Care
178. 3 This is the safest way to dry the cast evenly.
1 Besides the danger of burning the child, the cast may
dry on the outside and remain damp within. 2 This may
create a draft and be uncomfortable for the child.
4 This will impede the circulation of air and delay drying.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Fractures Throughout Childhood, Nursing Care
179. Answer: 2, 3.
1 Rest with elevation of the extremity is recommended;
strenuous activity should be avoided for several days.
2 When swelling of the fingers occurs, the cast can
become too tight, resulting in neurovascular damage;
permanent damage can occur in 6 to 8 hours. 3 The
g
casted arm should be in a sling when the child is upright
to promote venous return. 4 Joints above and below the
in
cast should be moved to maintain flexibility. 5 The casted
arm should be elevated when resting to promote venous
return.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 31, Fractures Throughout
Childhood, Nursing Care
180. 1 The immediate postburn period is marked by
dramatic changes in fluid and electrolyte balance.
Alterations in electrolyte balance can produce
confusion, weakness, cardiac irregularities, and
seizures. Secondary to large fluid losses through
the denuded skin, vasodilation, and edema
formation, hypovolemic shock may develop.
2 Pneumonia is a later complication associated with
immobility. 3 Contractures are a later complication
associated with scarring and aggravated by improper
positioning and splinting. 4 Hypotension, not
hypertension, occurs with hypovolemic shock.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Burns, Data Base
181. 2 Inhalation burns usually are present with facial
burns, regardless of the depth; the immediate
threat to life is asphyxia from irritation and edema
of the respiratory passages and lungs.
1 Although wound sepsis is a possible complication, it
will not be evident until the third to fifth day.
3 Although the child is probably fearful, maintaining a
patent airway is the priority. This child is too old for
separation anxiety; however, complications related to
stress can occur later. 4 Fluid losses can be extremely
high but reach their maximum about the fourth day; the
initial priority is maintaining a patent airway.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
31, Burns, Nursing Care
182. Answer: 3, 4.
1 This is a generalization that is not necessarily
true. 2 This is not a consideration in this situation.
3 The medication begins to work in minutes; doses can
be controlled. 4 Intramuscular medications are avoided
when possible to prevent inadequate absorption of the

medication because of damaged tissue. 5 The length of
effectiveness of an analgesic is based on its therapeutic
level in the body regardless of what route is used.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level; Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Burns, Nursing Care
183. 4 The early school-age child has become a
cooperative member of the family and will mimic
parents’ attitudes and food habits readily.
1 This does not have a major influence on eating
habits. 2 This certainly has some influence, though not
major, on eating habits. 3 The peer group does not
become influential until a later school age and during
adolescence.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Assessment/Analysis; Reference: Ch 31, Childhood
Nutrition
184. 4 Positioning on the right side after feeding
facilitates digestion because the pyloric sphincter is
rs
on this side and gravity aids in emptying the
stomach.
1 The feeding may begin immediately after opening the
nu
tube. 2 This may result in aspiration; the child’s head
and torso should be elevated. 3 If the gastrostomy tube
is flushed before or after a feeding, water, not normal
saline, is used.
Client Need: Basic Care and Comfort; Cognitive Level:
l_
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Burns, Nursing Care
185. 2 It is the nurse’s responsibility to assess tube
placement before each feeding; withdrawing gastric
ca
contents before each feeding ensures that the tip of
the tube is in the stomach.
1, 3, 4 This is not frequent enough; the tube could be
displaced between feedings.
i
Client Need: Basic Care and Comfort; Cognitive Level:
in
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Burns, Nursing Care
186. 3 Children with celiac disease have a gluten-induced
enteropathy and are unable to absorb fats from the
cl
intestinal tract, resulting in the typical
characteristics of their stools.
1 The stools are large and fatty or frothy, not mucoid.
@
2 Although the stools are large and frothy, they are pale
in color because of their high fat content. 4 The stools
are large and foul-smelling and have little color.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
31, Celiac Disease, Data Base
187. 2 Products composed of corn, rice, and millet do not
contain gluten and are permitted on a low-gluten
diet; tortilla chips are made from corn flour.
1 Pretzels contain wheat flour, which is not permitted
on a low-gluten diet; products containing rye, oats, and
barley are also restricted. 3 Oatmeal cookies contain
oats, which are not permitted on a low-gluten
diet. 4 Peanut butter crackers contain wheat flour,
which is not permitted on a low-gluten diet.
Answers and Rationales 755
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
CHILD HEALTH NURSING
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 31, Celiac Disease, Nursing
Care
188. 3 Both parents are carriers; the gene for cystic fibrosis
is recessive and the parents do not have the
disease.
1 The gene for cystic fibrosis is not a mutant
gene. 2 The gene for cystic fibrosis is not located on the
X or Y chromosome. 4 The gene for cystic fibrosis is
inherited as a recessive, not dominant, gene.
ANSWERS AND RATIONALES
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Cystic Fibrosis, Data Base
g
189. 3 Mucous secretions increase in viscosity and
precipitate or coagulate to form concentrations in
in
glands and ducts, which in turn cause obstructions.
Decreased amounts of pancreatic enzymes cause
impairment in the digestion and absorption of
nutrients.
1 The eccrine (sweat) glands are not hyperactive, but
there is an increased concentration of sweat electrolytes
(e.g., sodium and chloride). 2 The autonomic nervous
system does not play a role in the pathology of cystic
fibrosis. 4 There is no alteration in the mucosal lining of
the intestines.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Cystic Fibrosis, Data Base
190. 1 Because of a lack of the pancreatic enzyme lipase,
fats remain unabsorbed and are excreted in
excessive amounts in the stool.
2, 4 This does not cause the typical characteristics of the
stools. 3 These are the pancreatic enzymes, whose
passage into the intestine is prevented by blocked
pancreatic ducts.
Client Need: Physiological Adaptation; Cognitive Level:
Knowledge; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Cystic Fibrosis, Data Base
191. 2 When the causative organism is isolated, it is tested
for antimicrobial susceptibility (sensitivity) to
various antimicrobial agents. When a
microorganism is sensitive to a medication, the
medication is capable of destroying the
microorganism.
1 The tolerance of the child to the particular antibiotic
is unknown, since up to this time the child has not
developed any allergies. 3 Bacteria are not selective.
4 Although the health care provider may have a
preference for a particular antibiotic, it first must be
determined if the bacteria have exhibited sensitivity to it.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 30, Respiratory Tract Infections, Data Base
192. 2 Rectal prolapse is a common gastrointestinal
complication of cystic fibrosis and results from
wasting of perirectal supporting tissues, secondary
to malnutrition.
 756 CHAPTER 35 Child Health Nursing
1 Anal fissures may or may not occur with cystic
CHILD HEALTH NURSING
fibrosis. 3 Intussusception is not associated with cystic
fibrosis. 4 Meconium ileus is associated with cystic
fibrosis in newborns; it prevents the passage of
meconium.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Cystic Fibrosis; Data Base
193. 2 The nurse can best evaluate teaching by asking the
learner for a return demonstration. Behavior, rather
ANSWERS AND RATIONALES
than words, more readily shows what has been
learned.
1 The child may be too young to know if there are any
questions. 3 A demonstration rather than an
explanation can be evaluated more readily. 4 This is
difficult for a 5-year-old child; the ability to articulate a
concept is not that advanced, nor is the vocabulary.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 29,
rs
Principles Related to Medications for Children, Nursing Care
194. Answer: 250 mL/hr. Volume control devices function
on the concept of mL/hr; since the 125 mL must
infuse in 30 minutes, the rate should be set at
250 mL/hr to infuse 125 mL in 30 minutes.
nu
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 29, Principles Related to Medications for Children,
l_
Nursing Care
195. 2 Because the mucous glands secrete thick mucoid
secretions that accumulate, reducing ciliary action
and mucus flow, the nurse should perform postural
ca
drainage, which promotes the removal of
mucopurulent secretions by means of gravity.
1 Coughing should be encouraged; it helps bring up
secretions from the respiratory tract. 3 Although the
i
nurse should encourage activities appropriate for the
in
child’s physical capacity, the child’s energy should be
conserved during acute phases of illness. 4 This is not
necessary; the child with cystic fibrosis can eat regular
meals at the usual times.
cl
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Cystic Fibrosis, Nursing Care
@
196. 3 This regimen will give the child an opportunity to
rest before eating.
1 The child should be encouraged to cough; if it is not
effective, suctioning can be done after chest percussion
and postural drainage. 2 Chest percussion and drainage
should be done after aerosol therapy. 4 This may cause
the child to vomit.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Cystic Fibrosis, Nursing Care
197. 3 Cystic fibrosis is characterized by an overproduction
of viscous mucus by exocrine glands in the lungs.
The mucus traps bacteria and foreign debris that
adhere to the lining and cannot be expelled by the
cilia, thus obstructing the airway and favoring
growth of microorganisms and infection.
1 Cardiac defects are not associated with cystic
fibrosis. 2 Neuromuscular irritability of the bronchi
does not occur in cystic fibrosis. 4 Although there is
increased sodium and chloride in the saliva, these do not
irritate or inflame the mucous membranes.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Cystic Fibrosis, Data Base
198. 1 Because children with cystic fibrosis do not absorb
the fat-soluble vitamins effectively, they should be
given in a water-miscible form.
2 These vitamins can be given with other vitamins once
a day; pancreatic enzymes are administered with meals
and snacks. 3 The nurse does not have to calibrate a
g
dose of these vitamins based on the child’s height and
weight. 4 There is no reason to select juice over milk
in
when administering these vitamins.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Cystic Fibrosis, Data Base
199. Answer: 2, 4, 5.
1 Steroids are not indicated in the treatment of cystic
fibrosis. 2 Antibiotics are prescribed to treat recurrent
respiratory tract infections. 3 Antihistamines are not
used because of the drying effect on the already tenacious
mucus secretions. 4 Thick secretions obstruct the
pancreatic ducts, and essential pancreatic enzymes are
blocked from reaching the duodenum; therefore,
pancreatic enzymes are administered with meals to assist
with digestion. 5 Fat-soluble vitamins are necessary
secondary to the decreased absorption of fat.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Cystic Fibrosis, Nursing Care
200. 1 Pinworms emerge nocturnally to lay eggs in the
perianal area; eggs are transferred onto transparent
tape in the morning before toileting.
2 A culture will not reveal the presence of parasites.
3 Ova cannot be seen with the naked eye; the parasite is
rarely observed in the stool. 4 This is not a test to
diagnose pinworms.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Pinworms,
Data Base
201. 4 The adult pinworm lives in the rectum or colon and
emerges onto the perirectal skin during the hours
of sleep, depositing its eggs during this time.
1, 2, 3 Pinworms attach to the bowel wall and do not
emerge from the rectum at this time.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Pinworms,
Data Base
202. 4 Pinworms attach to the bowel wall in the cecum and
appendix and can damage the mucosa, causing
appendicitis.
1 Pinworms do not migrate to the liver. 2 Although
pinworms (and their ova) are ingested by mouth, they do

not attach there; inflammation of the mouth is not a
complication of pinworm infestation. 3 Pinworms do
not migrate to the respiratory system.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 31, Pinworms, Data Base
203. 4 All household members should be treated at the
same time unless they are younger than 2 years of
age or pregnant.
1 This drug is not recommended for children under the
age of 2 years. 2 This is not a significant criterion for
administration of medication because the eggs are
airborne. 3 Positive testing is not a criterion for
administration to family members.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Pinworms, Nursing Care
204. 4 This is the expected response because the
medication causes death of the worms.
1 Neither the drug nor the worms cause intestinal
rs
bleeding. 2 Transient diarrhea, not constipation, may
occur. 3 The medication can color the stool red, not
yellow.
nu
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 31,
Pinworms, Nursing Care
205. 1 As the mite burrows into skin folds (e.g.,
l_
interdigital, axillary, inguinal), it creates threadlike
burrows that are intensely pruritic.
2 Grayish white particles adhering to hair shafts are nits,
an indicator of pediculosis capitis, not scabies. 3 This is
ca
not an indicator of scabies; the bite of a brown recluse
spider causes a lesion that progresses to necrotic
ulceration in 7 to 14 days. 4 Reddened areas of alopecia
are consistent with ringworm, not scabies.
i
Client Need: Physiological Adaptation; Cognitive Level:
in
Application; Nursing Process: Planning/Implementation;
Reference: Ch. 33, Scabies, Data Base
206. 2 A potty chair allows the child to display its
contents with pride; sitting on top of a toilet seat
cl
is frightening for many children. Potty chairs
also allow the child to place feet on the floor for
an effective Valsalva maneuver for bowel
@
evacuation.
1 Sitting on a toilet seat can be frightening for a toddler;
timing of bowel training should coincide with the
gastrocolic reflex. 3 Bowel training should begin when
the child shows readiness. 4 A diet consisting mainly of
solid foods will make stools more bulky and easier to
control.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Growth and Development, Major Learning Events
207. 3 Dehydration promotes the sickling of erythrocytes.
Increased fluid intake minimizes the chance that a
sickle cell pain episode will reoccur.
1 This is not necessary or helpful for a child with sickle
cell anemia. 2 Rigorous exercise is contraindicated
Answers and Rationales 757
because the decrease in oxygenation may cause
CHILD HEALTH NURSING
sickling. 4 This is not necessary.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Sickle Cell
Anemia, Nursing Care
208. 1 The child is having an allergic reaction, and the
infusion must be stopped immediately to prevent
serious complications.
2 Slowing the rate of infusion will not halt the allergic
reaction to the transfused blood. 3 This is dangerous as
ANSWERS AND RATIONALES
an initial action because the degree of allergic reaction
cannot be determined at this time. Also, it requires a
health care provider’s prescription. 4 The health care
g
provider should be notified after the infusion has been
stopped.
in
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, β-Thalassemia, Nursing Care
209. 3 Folic acid acts as a necessary coenzyme in the
formation of heme, the iron-containing protein in
hemoglobin.
1 Calcium is not involved in the production of RBCs.
2 Thiamine is a coenzyme in carbohydrate metabolism.
4 Riboflavin is a control agent for energy production
and tissue formation.
Client Need: Basic Care and Comfort; Cognitive Level:
Knowledge; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Iron
Deficiency Anemia, Nursing Care
210. Answer: 1, 3.
1 Protein is essential for the synthesis of the blood
proteins, albumin, fibrinogen, and hemoglobin.
2 Calcium is not involved in the synthesis of red blood
cells. 3 Vitamin C (ascorbic acid) influences the removal
of iron from ferritin (making more iron available for the
production of heme) and influences the conversion of
folic acid to folinic acid. 4 Vitamin D is not involved in
the synthesis of red blood cells. 5 Carbohydrates are not
involved in the synthesis of red blood cells.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 31, Iron Deficiency
Anemia, Nursing Care
211. 3 A diet of only milk is not sufficient to meet the
infant’s iron needs. Meat and fortified cereals are
high in iron. Finger foods are appropriate for older
infants.
1 At this age weaning from the bottle is not the issue;
supplementary iron intake is. 2 Although health care
and monitoring will be required, the metabolic clinic is
not the appropriate referral. 4 Although this will
increase iron intake, it is not appropriate for a 1-year-old
infant, nor is it desirable.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 31, Iron
Deficiency Anemia, Nursing Care
212. 1 β-Thalassemia is common in children who are black
or of Mediterranean descent (Italian, Greek, Syrian);
 758 CHAPTER 35 Child Health Nursing
an enlarged abdomen may be due to hepatomegaly
CHILD HEALTH NURSING
or splenomegaly.
2 Pale skin is expected in children of Irish descent;
children with β-Thalassemia may have a bronze skin
color from hemosiderosis if not chelated. 3 Defective
hemoglobin leads to damaged RBCs and a decreased
hematocrit. 4 Asian descent is not a risk factor for
β-Thalassemia.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
ANSWERS AND RATIONALES
Reference: Ch. 31, β-Thalassemia, Nursing Care
213. 3 Children with a chronic illness, such as hemolytic
anemia, should not be exposed to the additional
stress of infection.
1 A regular intake of fluid is recommended. 2 Activity
is not restricted, although the child may self-restrict
activity because of anemia-induced fatigue. 4 Regular
meals with the family should be encouraged.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
rs
Process: Planning/Implementation; Reference: Ch 31,
β-Thalassemia, Nursing Care
214. 2 In this type of episode there is a pooling of blood in
the liver and spleen, with a decreased circulating
blood volume and subsequent shock.
nu
1 These are the characteristics of a vaso-occlusive crisis.
3 Decreased RBC production and the profound anemia
that ensues are characteristics of aplastic crisis.
l_
4 Increased RBC destruction and a concomitant anemia,
jaundice, and reticulocytosis are characteristics of
hyperhemolytic crisis.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
ca
Nursing Process: Assessment/Analysis; Reference: Ch 31, Sickle
Cell Anemia, Data Base
215. 1 Dehydration, stress, infection, and electrolyte
imbalance can cause the sickling process. Red
i
blood cells change to the sickle shape when
in
deoxygenated because of polymerization of the
abnormal hemoglobin. This process damages the
RBC membrane, which causes the cells to become
entangled in the blood vessels. This deprives the
cl
tissues that are distal to the occlusion of oxygen,
resulting in ischemia and infarction, which can
result in organ damage.
@
2 The child’s condition determines the activity level;
although bed rest may be required during a pain
episode, at other times it is rarely necessary. 3 This will
not prevent thrombus formation. 4 Anticoagulants do
not help prevent thrombus formation in sickle cell
anemia.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Sickle Cell Anemia, Nursing Care
216. 4 Cardiac decompensation results because the heart
attempts to maintain tissue oxygenation by
increasing its workload.
1 Shock occurs with hemorrhage because the body does
not have time to adapt to the sudden loss of blood. With
chronic anemia, compensatory mechanisms take over.
2 An elevated WBC count indicates that there is an
infection; however, the data do not indicate the presence
of an infection. 3 Hemoglobin in the urine suggests
hemolytic anemia. Although it is important to assess for
the cause of the anemia, it is not the priority.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Iron Deficiency Anemia, Data Base
217. 2 Warmth causes vasodilation, which will lessen the
pain of the vaso-occlusive crisis.
1 Cold will cause more vasoconstriction and increase
pain. 3 This is an inadequate dose for an adolescent.
4 IV fluids should be increased to dilute the blood and
prevent further sickling.
g
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
in
Reference: Ch 31, Sickle Cell Anemia, Nursing Care
218. 2 Children with both illnesses have inadequate
resistance to infection. Sickling results from low
oxygen levels; celiac crisis results from
malnourishment and immunologic defects.
1 Activity need not be limited in celiac disease;
strenuous activity should be limited in sickle cell
anemia. 3 This is important for children with celiac
disease; it is not necessary for children with sickle cell
anemia. 4 This diet is not particularly helpful for
children with sickle cell anemia or celiac disease.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 31, Sickle Cell Anemia, Nursing Care
219. Answer: 2, 3.
1 Although nutrition is important, it is not a major
concern during a crisis. 2 Hydration is necessary to
promote and maintain hemodilution. 3 Pain in the area
of involvement is a major problem and demands priority
care. 4 Although important for these children, during a
crisis prevention of infection is not the major concern. 5
Oxygen may be helpful to prevent further sickling, but it
is not effective in reversing sickling because it cannot
penetrate the sickled RBCs in the clogged blood vessels
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 31,
Sickle Cell Anemia, Nursing Care
Nursing Care of Preschoolers
220. 2 The child will self-move the hand over the
abdomen; the nurse can then engage the child’s
cooperation and do a general assessment.
1 Further assessment is necessary; it should be
determined whether the crying is due to pain or
fear. 3 The parents may hold, but not restrain, the child,
because this may increase anxiety. 4 This is not an initial
intervention; the child’s cooperation will be needed for
this procedure.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Assessment/
Analysis; Reference: Ch 32, Hospitalization of Preschoolers, Data Base

221. 3 Preschoolers generally have learned to cope with
parents’ absence; however, emotions associated
with separation are difficult to hide when parents
arrive or leave. Anger at being left also may account
for the emotional outburst.
1 Preschoolers enjoy social interaction and probably will
be cooperative. 2 Preschoolers have learned to cope with
their parents’ absence. 4 Preschoolers have developed
social skills with peers and will be able to interact with
them even when the other children’s parents are present.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Assessment/Analysis; Reference: Ch 32,
Hospitalization of Preschoolers, Data Base
222. 4 Referring the parent back to the health care
provider with a suggestion that addresses the need
for more information is an appropriate initial
intervention. The health care provider can
coordinate the referral to the appropriate
specialists (e.g., oncologist, hematologist).
rs
1 Although this is a true statement, it minimizes the
parent’s concern. 2 Although this may be done
eventually, it does not address the parent’s need for
level. This referral may be done eventually.
nu
information. 3 The Leukemia Society may disseminate
information, but it does not give advice on a personal
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
l_
Process: Planning/Implementation; Reference: Ch 32,
Hospitalization of Preschoolers, Data Base
223. 1 Children with nephrotic syndrome are treated with
immunosuppressive agents, including steroids.
ca
During exacerbations they may have a
characteristic pale, overweight appearance from
edema. Steroid side effects include growth
retardation, cataracts, obesity, and hirsutism.
i
Children may become very sensitive about these
in
changes as they grow older.
2 Although this may be indicated, body-image problems
pose a greater threat. 3 Engaging in usual childhood
activities between attacks should promote the
cl
development of fine muscle coordination. 4 Sterility is
not associated with nephrotic syndrome.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
@
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 32, Nephrotic Syndrome, Nursing
Care
224. 4 A classic sign of nephrotic syndrome is gross
proteinuria; a decrease indicates that treatment is
successful.
1 A child with nephrotic syndrome has gross edema and
oliguria; increased urine output is the desired outcome.
2 Children with glomerulonephritis have hematuria; it is
not expected in children with nephrotic syndrome.
3 Children with diabetes mellitus have glycosuria; it is
not expected in children with nephrotic syndrome.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 32, Nephrotic Syndrome, Data Base
Answers and Rationales 759
225. 3 This focuses on the child’s feelings and a familiar
CHILD HEALTH NURSING
object of security.
1 The child may experience pain as part of the
treatment, so the statement is untruthful. 2, 4 Diverting
the child’s attention will not alleviate fear and anxiety.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 32, Hospitalization of Preschoolers,
General Nursing Care of Preschoolers
226. 2 Fear of mutilation is typical of the preschooler
because they have vague views of body boundaries.
ANSWERS AND RATIONALES
1 Toddlers are more likely to fear separation from
parents. 3 Preschoolers do not view death as final.
4 Although preschoolers do indulge in magical thinking,
g
they have not yet developed the concept of supernatural
beliefs.
in
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 32, Hospitalization of Preschoolers, Data Base
227. 2 The anxiety that occurs in a 4-year-old child
regarding invasive procedures will be lessened
when the child holds the scope and realizes how it
will be used.
1 This is suggesting an unsafe activity. 3 This request
will more likely be accepted after the child has handled
the scope and recognizes what to expect. 4 Stating the
word “hurt” may increase anxiety; a 4-year-old child
thinks in concrete terms and probably will not believe
the nurse until experiencing the procedure.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 32, Hospitalization of Preschoolers, Data Base
228. 3 A few minutes will be enough time for the child
to begin self-feeding. The nurse should provide
both physical and emotional support because
the child’s request for help indicates regression
and the need for dependence during a period of
stress.
1 This does not provide the child with the help that
may be needed. 2 It may be a while until the child feels
better; in the meantime, adequate nourishment to
provide for healing is needed. 4 This can cause stress,
feelings of guilt, and embarrassment to a sick child.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Caring; Nursing Process:
Planning/Implementation; Reference: Ch 32, Hospitalization of
Preschoolers, Data Base
229. 1 The child may be fearful of the examining room
experience. If the nurse greets the child while in the
safety of the waiting room, it might help to make
the experience less threatening.
2 Calling the child without entering the room is an
authoritarian approach that will not limit the child’s
anxiety. 3 Having someone else bring the child into
the examining room is an authoritarian approach that
may make the child more fearful. 4 Standing at the
examining room door while the child walks down the
hall is an authoritarian approach that may increase the
child’s anxiety.
 760 CHAPTER 35 Child Health Nursing
Client Need: Health Promotion and Maintenance; Cognitive
CHILD HEALTH NURSING
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 32,
Hospitalization of Preschoolers, General Nursing Care of Preschoolers
230. 1 PredniSONE reduces the child’s resistance to certain
infectious processes. Also predniSONE is an
antiinflammatory drug that masks infection.
2 The child will self-limit activity based on the
respiratory status. 3 Eosinophil counts are often
consistently elevated in children with asthma. 4 The
child will need adequate hydration to assist with
ANSWERS AND RATIONALES
loosening and removing mucus.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 32, Asthma, Nursing Care
231. 4 Euphoria and mood swings may result from steroid
therapy.
1 Alopecia does not result from steroid therapy. 2 An
increased appetite, not anorexia, results from steroid
therapy. 3 Weight gain, not weight loss, results from
rs
steroid therapy.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 32, Leukemia, Nursing Care
232. 1 PredniSONE is a synthetic glucocorticoid that has
an active antiinflammatory effect by stabilizing
lysosomal membranes and thus inhibiting
proteolytic enzyme release.
nu
l_
2 PredniSONE does not affect the lymphocytes.
3 Although predniSONE increases the appetite and
creates a sense of well-being, these are not the reasons it
is administered. 4 There is no indication the child is
ca
receiving radiation.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 32, Leukemia, Data Base
i
233. Answer: 44 pounds. The child’s daily dose is 40 mg
in
(10 mg × 4 times a day). Divide the daily dose of
40 mg by 2 mg/kg/day, which equals 20 kg.
Since 1 kg is equal to 2.2 lb, multiply 20 × 2.2,
which equals 44 lb.
cl
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 29, Principles Related to Medications for Children,
@
Nursing Care
234. 4 VinCRIStine is highly neurotoxic, causing
paresthesias, muscle weakness, ptosis, diplopia,
paralytic ileus, vocal cord paralysis, and loss of deep
tendon reflexes.
1 Hematologic effects are rare. 2 Alopecia is reversible
with cessation of the drug. 3 There are no severe
gastrointestinal effects.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 32, Leukemia, Nursing Care
235. 1 Children with leukemia most often die of infection;
a low neutrophil count is associated with
myelosuppressant therapy.
2 These measures are not appropriate to prevent
infection resulting from neutropenia; they are appropriate
for treating the anemia. 3 These measures are not
appropriate to prevent infection resulting from
neutropenia; they are more appropriate for preventing
bleeding. 4 These measures are not appropriate to
prevent infection resulting from neutropenia; they are
used to treat stomatitis.
Client Need: Safety and Infection Control; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation; Reference:
Ch 32, Leukemia, Nursing Care
236. 1 The child from 1 to 4 years of age is learning to
use the body and manipulate and experiment with
all aspects of the environment; these abilities may
challenge the nursing assistant, especially when
taking vital signs.
g
2 The school-age child is able to cooperate and
understand when receiving care; however, modesty
in
should be respected. 3 From 6 to 12 months of age, it
usually is helpful while giving care to have the infant
held on the parent’s lap to limit stranger anxiety or to
allow the parent to provide basic care (e.g., changing
diapers, bathing). 4 Infants usually are not a challenge
to care for. The infant usually is easily distracted with
sounds and smiles.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 32, Hospitalization of Preschoolers, Data Base
237. 3 Role-playing encourages expression of concerns
through behavior, since children’s ability to
verbalize feelings is limited.
1 The preschooler is too young to think about careers.
2 This may occur, but it is not a purpose of role-
playing. 4 Although preschoolers try to imitate adults,
providing guidelines for adult behavior is premature.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 32, Health Promotion of Preschoolers Play
238. 4 It is common for 4-year-old children to boast and
exaggerate and to be impatient, noisy, and selfish.
1 More advanced, cooperative play is expected of
4-year-old children. 2 This is unusual for 4-year-old
children, since they are striving toward more initiative
and less dependence. 3 The toddler’s tendency toward
tantrums and negativism should have waned by 4 years
of age.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 32, Health Promotion of Preschoolers Play
239. 3 Most 4-year-old children are imaginative; because
the line between fantasy and reality is blurred,
imaginary playmates are common at this age.
Generally, they are given up when the child starts
school.
1 This assumption is not relevant at this age; it becomes
a concern when the child reaches school age. 2, 4 This
response may cause unnecessary concern; it provides false
information.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 32,
Health Promotion of Preschoolers, Play

240. 2 Fear of mutilation and intrusive procedures is most
common at this age because of fantasies and active
imagination. These children also connect illness
with being bad and view intrusion as punishment.
1 Death is seen as reversible and not final. 3 A child
this age usually has little previous contact with pain and
therefore little experience on which to base fear. 4 Fear
of isolation from peers is a problem for school-age
children and adolescents.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Caring; Nursing
Process: Assessment/Analysis; Reference: Ch 32, Hospitalization of
Preschoolers, Data Base
241. 1 Because their ability to express feelings verbally is
limited, preschool children act out their feelings via
play.
2 Acceptance of hospitalization will not occur until the
child has coped with fears. 3 The child needs to cope
with feelings rather than forget them. 4 Therapeutic
play does not necessarily involve other children.
rs
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 32, Hospitalization of Preschoolers,
General Nursing Care of Preschoolers
242. 1 Nonstrenuous, diversional activities involving
interpersonal relationships with another person
nu
provide better support and resting conditions than
does more active play.
l_
2 A jigsaw puzzle is too complicated for a 5-year-old
child and does not provide the human contact needed.
3, 4 Although this is an age-appropriate distraction, it
does not provide the human contact needed.
ca
Client Need: Psychosocial Integrity; Cognitive Level: Analysis;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Hospitalization of Preschoolers, General
Nursing Care of Preschoolers
i
243. 4 Gas exchange is limited because of narrowing and
in
swelling of the bronchi; the carbon dioxide level
increases.
1 The oxygen level will be decreased, not increased.
2 The pH will decrease; the child is in respiratory
cl
acidosis, not alkalosis. 3 The bicarbonate level will be
increased to compensate for acidosis.
Client Need: Reduction of Risk Potential; Cognitive Level:
@
Application; Nursing Process: Assessment/Analysis; Reference: Ch
32, Asthma, Data Base
244. 4 Cold and exercise can precipitate bronchospasm,
and increased exercise depletes oxygen.
1 Treatment of asthma does not involve a low-fat
diet. 2 Asthma is a chronic condition. Return to usual
activities after the acute stage is essential for growth and
development. 3 Although increased protein and calories
may be needed to support the child during a coexisting
bacterial infection in the acute stage, a return to usual
eating habits is indicated by the time of discharge.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 32, Asthma, Nursing Care
245. Answer: 1, 4.
Answers and Rationales 761
1 Parents should be taught to limit allergens in the
CHILD HEALTH NURSING
home that can precipitate asthma attacks (e.g., no
carpets, no down pillows, wet-mop floors, vacuum when
the child is not in the home, no scented household
products). 2 Environmental moisture is necessary for
these children; in addition, cold environments should
be avoided. 3 Consistent limits should be placed on
the child’s behavior regardless of the illness; a chronic
illness does not eliminate the need for limit setting.
4 Medications to control inflammation, including
ANSWERS AND RATIONALES
inhaled corticosteroids and long-acting beta 2-agonists,
must be continued to suppress exacerbations of asthma.
5 The child should return to school and continue to
interact with schoolmates and friends.
g
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
in
Process: Planning/Implementation; Reference: Ch 32, Asthma,
Nursing Care
246. Answer: 3, 4.
1 An elevated temperature is a characteristic of sepsis,
not asthma. 2 Crackles are associated with pulmonary
edema, not asthma. 3 Bronchial constriction with
mucus production causes wheezing. 4 With the decrease
in arterial oxygenation associated with asthma, the heart
rate will increase. 5 Hypertension, not hypotension, may
occur with asthma.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 32, Asthma,
Data Base
247. 3 The restricted ventilation accompanying an asthma
attack limits the body’s ability to blow off carbon
dioxide. As carbon dioxide accumulates in the body
fluids, it reacts with water to produce carbonic acid;
the result is respiratory acidosis.
1 The problem basic to asthma is respiratory, not
metabolic. 2 Respiratory alkalosis is caused by exhaling
large amounts of carbon dioxide; asthma attacks cause
carbon dioxide retention. 4 Asthma is a respiratory
problem, not a metabolic one; metabolic acidosis can
result from an increase of nonvolatile acids or a loss of
base bicarbonate.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 32, Asthma,
Data Base
248. 3 The seepage of blood from the operative site drains
into the oral cavity, causing the child to swallow.
1 Snoring can be expected after a tonsillectomy because
of edema. 2 Because the child has been NPO for an
extended time and is not able to swallow fluids easily, the
child will probably ask for fluids. 4 This may be a later
sign of hemorrhage.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 32, Tonsillectomy and Adenoidectomy, Nursing Care
249. 1 Ice chips are soothing and promote
vasoconstriction.
2 Milk and milk products coat the mouth, causing the
child to clear the throat, which may precipitate
bleeding. 3 The supine position promotes edema and
 762 CHAPTER 35 Child Health Nursing
does not allow oral secretions to drain from the mouth.
CHILD HEALTH NURSING
The head of the bed should be elevated, and the child
should be positioned on the side. 4 Mouthwash solution
is too caustic; a warm saltwater solution is preferred.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 32,
Tonsillectomy and Adenoidectomy, Nursing Care
250. 1 The characteristic “strawberry tongue” is due to
sloughing of the normal coating of the tongue,
leaving the papillae exposed.
ANSWERS AND RATIONALES
2 There is bilateral congestion of the ocular conjunctiva
without an exudate. 3 The fever associated with
Kawasaki disease is high and has an abrupt onset; it is
unresponsive to antibiotics and antipyretics. 4 A
maculopapular rash on the extremities does not occur;
peripheral edema and erythema occur with desquamation
of the palms of the hands and soles of the feet.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
rs
32, Mucocutaneous Lymph Node Syndrome, Data Base
251. 3 Infection is a constant threat because of a poor
general state of nutrition, a tendency toward skin
breakdown in edematous areas, corticosteroid
therapy, and lowered immunoglobulin levels.
nu
1 Although intake of foods with high nutritional value
should be encouraged, this is not the priority. 2 Fluid
monitoring is important in determining whether a fluid
l_
restriction is indicated. 4 Bed rest may be needed for
severe edema, but ambulation is preferred.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
ca
Reference: Ch 32, Nephrotic Syndrome, Nursing Care
252. 1 Poor appetite and decreased energy are associated
with the accumulation of toxic waste; anemia
accounts for the pallor.
i
2 Activity does not cause these signs and symptoms.
in
3 An elevated temperature probably will be present, but
an infection will not cause a muddy pallor.
4 Discontinuing the corticosteroids and diuretics that
usually are prescribed will probably result in recurrence
cl
of edema in steroid-dependent children.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 32,
@
Nephrotic Syndrome, Nursing Care
253. 3 A renal biopsy is an invasive procedure. In the early
stages, Wilms tumor is encapsulated. Any disruption
of the tumor capsule may precipitate metastasis.
1 An MRI is helpful in making the diagnosis. 2 A CT
scan is helpful in making the diagnosis. 4 An abdominal
ultrasound is helpful in making the diagnosis.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 32,
Wilms Tumor, Nursing Care
254. Answer: 1, 2.
1 There is an increase in appetite that results in
deposition of fat on the abdomen and trunk. 2 Muscle
wasting results in thin extremities. 3 Increased excretion
of calcium causes a retarded linear growth with a short
stature. 4 Because of the excess production of
androgens, virilization and hirsutism occur. 5 Increased
salt and water retention cause hypertension and
hypernatremia.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Evaluation/Outcomes;
Reference: Ch 32, Nephrotic Syndrome, Nursing Care
255. 1 Comparison of daily weights is the most accurate
way to assess fluid retention or loss.
2 This is difficult for a child this age and will not be
accurate. 3 This is a measure for the degree of ascites; it
indirectly measures fluid retention. 4 Assessment of
urine for protein gives information about the disease
g
process but not about the amount of fluid retention.
Client Need: Basic Care and Comfort; Cognitive Level:
in
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 32, Nephrotic Syndrome, Nursing Care
256. Answer: 1, 2, 4.
1 Pallor is the result of anemia associated with
leukemia. 2 Fatigue is the result of anemia associated
with leukemia. 3 Jaundice usually indicates liver damage
or excessive hemolysis and is not an early sign of
leukemia. 4 Multiple bruises are the result of
thrombocytopenia associated with leukemia. 5 Edema is
not a manifestation of the disease because the
pathophysiology does not involve transport of fluids.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 32,
Leukemia, Data Base
257. 2 Because of the increased capillary fragility and
decreased platelet count that accompany leukemia,
even the slightest trauma can cause hemorrhage.
Brushing the teeth has caused gingival bleeding,
and the incident should be documented; this
information may also assist in defining the
treatment plan.
1 It is wiser to eliminate a toothbrush and use a sponge-
type applicator. 3 It cannot be assumed that a 4-year-
old child will or can follow such a direction. 4 This can
irritate the gums, causing more trauma. If oral ulcers
develop, the mouth should be rinsed with an isotonic
solution such as normal saline.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Evaluation/Outcomes;
Reference: Ch 32, Leukemia, Nursing Care
258. 4 Radiation is used to destroy leukemic cells in the
brain because chemotherapeutic agents are
inadequately absorbed through the blood-brain
barrier.
1 Chemotherapy is required to treat the systemic
leukemic process. 2 Radiation does not reduce the risk
for infection. 3 Cranial radiation has no effect on the
systemic leukemic process.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 32, Leukemia,
Data Base
 Answers and Rationales 763

264. 4 The goiter associated with Hashimoto disease

Nursing Care of School-Age Children

CHILD HEALTH NURSING

usually is transient and regresses spontaneously
in 1 or 2 years. The child usually is euthyroid but
259. 1 Regression is expected in times of stress. It is a
may show signs of hypothyroidism or
transient need that should be accepted because it
hyperthyroidism.
helps reduce anxiety.
1 This is not a chronic disease. 2 This is not an
2 Distraction works only as long as it is employed. 3 It
untreatable or fatal disorder; it can be controlled with a
is the nurse’s responsibility to identify the child’s response
medical regimen. 3 There seems to be a strong genetic
to hospitalization and address the child’s needs at this
predisposition, but no mode of inheritance has been
time. 4 Cause (thumb-sucking) and future effect
identified.
(buckteeth) will not be meaningful to a 6-year-old child;

ANSWERS AND RATIONALES

Client Need: Physiological Adaptation; Cognitive Level:
furthermore, thumb-sucking may or may not cause Comprehension; Integrated Process: Teaching/Learning; Nursing
malocclusion. Process: Planning/Implementation; Reference: Ch 30,
Client Need: Health Promotion and Maintenance; Cognitive Level: Hypothyroidism, Data Base

Application; Integrated Process: Caring; Nursing Process:
Planning/Implementation; Reference: Ch 33, Hospitalization of
School-Age Children, General Nursing Care of School-Age Children
g
265. 2 Allowing the child to participate in the procedure
provides the child with some control over a

in
frightening experience.
260. 2 The nurse is seeking clarification while encouraging
1 Offering medication and using the word “hurt” may
each child to communicate verbally, rather than
increase anxiety. 3 Using the word “hurt” may increase
expressing their differences physically.
anxiety. The child will be hypervigilant and will not

rs
1 This is accusatory and nontherapeutic. 3 This is a
follow the directions to close the eyes. 4 Distraction
threatening response. 4 This is not relevant; the nurse
will be unsuccessful in this situation; the child is afraid,
should be concerned with the present situation.
Client Need: Health Promotion and Maintenance; Cognitive
and a passive activity will be insufficient to reduce
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
nu
Reference: Ch 32, Health Promotion of School-Age Children, Play
261. 1 The priority is to assess the throat to determine the
extent of inflammation. Significant swelling can
anxiety.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 33, Hospitalization of School-Age Children, General
l_
Nursing Care of School-Age Children
create the potential for airway obstruction.
266. Answer: 1, 2, 3.
2, 3, 4 Assessment of the child’s problem must be done
1 School-age children are creative and have the
before initiating any other actions.
manipulative skills to color in coloring books. 2 School-
ca

Client Need: Reduction of Risk Potential; Cognitive Level:

Application; Nursing Process: Assessment/Analysis; Reference: Ch
30, Respiratory Tract Infections, Nursing Care
262. 4 According to Piaget’s cognitive development
theory, school-age children use concrete
i
age children enjoy collections, and many 6-year-old
children collect small metal cars; it also supports
imaginative play. 3 School-age children enjoy
competition and have manipulative skills necessary to

operational thinking; a general discussion in manipulate cards. 4 This is more appropriate for the
in

concrete terms will be understood and transferred toddler or preschooler, who is developing fine motor
to the actual situation. skills. 5 This activity is too passive and ignores the
1, 2 This requires conceptual thinking, which is just 6-year-old child’s developmental needs.
Client Need: Health Promotion and Maintenance; Cognitive
cl

beginning to develop during the school-age years;

Level: Analysis; Nursing Process: Planning/Implementation;
8-year-old children are not ready for this thought
Reference: Ch 33, Health Promotion of School-Age Children, Play
process. 3 These children are capable of understanding a
267. 4 Six-year-old children are aware of their hands as
concrete explanation; this request belittles them.
@

tools and enjoy building simple structures.

Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 33,
Growth and Development, Developmental Timetable
263. Answer: 2, 5.
1 Hepatic side effects, such as jaundice, may occur but
are not common. 2 Nausea and vomiting may occur
due to gastrointestinal irritation. 3 CNS side effects,
such as headache, are rare adverse reactions. 4 This is a
rare side effect. 5 Hypersensitivity reactions such as skin
rash, erythema, fever, and pruritus occur with much
greater frequency in children and adults with AIDS.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Evaluation/Outcomes;
Reference: Ch 3, Infection, Related Pharmacology, Sulfonamides
1 This is more appropriate for preschoolers. 2, 3 This is
more useful for an older school-age child, who has a
longer attention span and a better ability to follow
instructions.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 33, Health Promotion of School-Age Children, Play
268. 4 The peripheral line must be used until the
placement of the central venous line is confirmed
by radiography or fluoroscopy; this prevents fluid
from entering the lung or interstitial space if the
catheter is misplaced.
1, 3 The central line should not be used until placement
is confirmed. 2 Drugs and fluids can be administered
 764 CHAPTER 35 Child Health Nursing
through central venous lines; most devices have multiple
CHILD HEALTH NURSING
ports.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 29, Principles Related to Medications for Children,
Nursing Care
269. Answer: 2, 3.
1 This is a solitary activity that will increase the child’s
boredom. 2 School-age children have an interest in
hobbies or collections of various kinds as a means of
gathering information and knowledge about the world in
ANSWERS AND RATIONALES
which they live. 3 School-age children are industrious,
and making a model airplane is an appropriate age-
related activity. 4 This will not interest the average
9-year-old child. 5 These probably will not interest a
9-year-old child.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 33, Health Promotion of School-Age Children, Play
270. 1 The reserved student should be given the
rs
opportunity to interact with peers.
2 The class clown may not be able to accept the
responsibility needed for a leadership role. 3 The child
difficulty interacting with the nurse in a new
role. 4 Although the outgoing child probably will be
nu
who has an established nurse-client relationship may have
able to take on added responsibility, the child does not
need help with social interaction.
l_
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 33,
Health Promotion of School-Age Children, Play
271. 4 Because young children have difficulty verbalizing
ca
their fears or anxiety, therapeutic play helps them
express these feelings.
1 A child this age is unable to express feelings entirely
through words. 2 This may be helpful for a toddler or
i
preschooler; school-age children need to act out their
in
fears. 3 Young school-age children are still somewhat
egocentric and therefore interested in their own
experiences and sensations.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
cl
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 33, Hospitalization of School-Age
Children, General Nursing Care of School-Age Children
@
272. 2 Eight-year-old children are beginning to achieve a
sense of industry and accomplishment. They are in
Piaget’s stage of concrete operations wherein they
are able to use their thought processes to
experience actions. Their growing independence
enables them to make decisions based on what
they have learned.
1 Six-year-old children are just beginning to experience
the developmental goals of the school-age child. They are
not ready to make choices based upon what they have
learned. 3 Preadolescents are beginning to assert their
independence and probably will rebel if taught what they
should eat. 4 Adolescents need to conform to their peer
group. What is learned in a nutrition class probably will
be ignored in favor of preestablished preferences.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Assessment/Analysis; Reference: Ch 33, Growth and
Development, Developmental Timetable
273. 4 Studies have shown that culture and family eating
habits have an impact on a child’s eating habits.
1 Inheritance is not known to influence eating habits,
although it is believed that there may be hereditary
factors associated with obesity. 2 Childhood obesity is a
known predictor of adult obesity. 3 Although there is a
trend toward this, with intervention it can be prevented.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis; Reference: Ch 33, Obesity,
Nursing Care
g
274. 3 There may be a weight gain caused by the influence
of hormones before the growth spurt. Most 10- to
in
12-year-old children can eat an adult-size meal
without becoming obese, especially if they are
active.
1 Before advising increased activity, the nurse should
assess the child’s present activity level. 2 An adequate
caloric intake is needed for the growth spurt that will
occur during adolescence. 4 Family eating patterns
appear to have more effect on weight than do genetics.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 33,
Growth and Development, Developmental Timetable
275. 3 School-age children lose their primary teeth, which
may be aspirated during surgery. Special
precautions must be taken to maintain safety.
1 This is a comforting gesture, but it is not
essential. 2 There is no reason to obtain an
antistreptolysin O (ASO) titer or a C-reactive protein
level. 4 This is important but not always possible.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 33,
Hospitalization of School-Age Children, General Nursing Care of
School-Age Children
276. 4 To maintain the desired blood level, the medication
must be administered in the exact amount at the
times directed. If the blood level of the drug falls,
the microorganisms have an opportunity to build
resistance to the drug.
1 Weighing is important with drugs that affect fluid
balance. 2 Sulfa medications should be given on an
empty stomach to promote absorption. 3 Monitoring
the temperature is important with antipyretic drugs.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 29, Principles Related to Medications for Children,
Nursing Care
277. Answer: 1, 2, 3, 4, 5.
1 The inflammatory process in the kidney allows red
blood cells to enter the urine, which manifests as
hematuria. 2 Capillary permeability in the kidney allows
protein to pass into the urine. 3 The glomerular
filtration rate is reduced, resulting in sodium retention;

fluid accumulation is evidenced by periorbital edema in
the morning, which spreads to the rest of the body as the
day progresses. 4 When the glomerular filtration rate is
reduced, fluid is retained as evidenced by a decreased
urinary output; with a decreased urinary output the
specific gravity will increase (1.030). 5 The retention of
fluid causes an increase in the intravascular volume,
resulting in an increased blood pressure.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 33, Acute
Post Streptococcal Glomerulonephritis, Data Base
278. 3 During the acute stage, anorexia and general
malaise lower the child’s resistance to infection.
1 A bland diet is not necessary, but high-protein and
high-sodium foods should be avoided. 2 Bed rest is not
a necessary restriction. It is encouraged when the child is
easily fatigued. 4 Antibiotics are not necessary for all
children with acute glomerulonephritis, only those with
persistent streptococcal infections. The intramuscular
route is not used.
rs
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 33, Acute Post Streptococcal Glomerulonephritis,
Nursing Care
279. 4 When urinary findings are within the expected
nu
range (e.g., no hematuria or proteinuria), the child
may resume preillness activities.
1, 2 This restriction is unnecessary. 3 Bed rest is
l_
unnecessary.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 33,
ca
Acute Post Streptococcal Glomerulonephritis, Nursing Care
280. 1 The use of aspirin to treat the fever associated with
influenza is contraindicated; it is associated with
Reye syndrome, a syndrome that involves a toxic
i
encephalopathy and hepatic dysfunction.
in
2 Inactivated influenza viral vaccines are effective in
prevention of influenza. 3 Fever may lead to
dehydration; fluids help maintain hydration. 4 The
influenza virus can be spread by direct contact or
cl
contact with surfaces contaminated with the virus;
staying home prevents the spread of the disease to other
students.
@
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcome; Reference: Ch. 33, Reye Syndrome,
Nursing Care
281. 1 Daily changes in weight are indicators of fluid
changes; loss or gain of muscle and fat does not
cause daily fluctuations in weight.
2 Protein molecules do not weigh enough to be reflected
in the child’s weight on a daily basis. 3 When fluid
weight gain, not loss, stops, the disease is being
controlled. 4 It is not beneficial to plan the child’s daily
caloric intake on fluid weight loss or gain.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Acute Post
Streptococcal Glomerulonephritis, Nursing Care
Answers and Rationales 765
282. 2 The child has an elevated blood pressure that can
CHILD HEALTH NURSING
cause hypertensive encephalopathy, resulting in
hyperperfusion of the brain and cerebral edema;
one of the early signs of encephalopathy is a severe
headache.
1 Rapid respirations do not cause a severe headache.
3 Anemia does not cause a severe headache. 4 The
autoimmune response associated with APSGN is not the
cause of the severe headache.
Client Need: Physiological Adaptation; Cognitive Level:
ANSWERS AND RATIONALES
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Acute Post
Streptococcal Glomerulonephritis, Data Base
283. 1 A physical therapist can prescribe an exercise
g
protocol to keep the joints as mobile as possible; a
routine can be developed to help the child alleviate
in
morning stiffness.
2 Although this might be necessary in the future, there
is no evidence that it is needed at this time. 3 Although
nutrition is an appropriate part of therapy, it is the
physical therapy program that can most directly influence
movement. 4 Over-the-counter medications should
not be used without the supervision of a health care
provider.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 33, Juvenile
Idiopathic Arthritis, Nursing Care
284. 3 Hematuria may result from the use of nonsteroidal
antiinflammatory drugs (NSAIDs) because they may
cause nephrotoxicity.
1 This can occur but is not a sign of toxicity. 2 This
does not occur with NSAIDs. 4 Drowsiness, not
hyperactivity, may occur.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 33,
Juvenile Idiopathic Arthritis, Nursing Care
285. Answer: 1, 2, 4.
1 This helps maintain joint mobility while not creating
weight-bearing on the joints. 2 This promotes
functional movement. It is a low-impact activity
compared to most outdoor activities that may employ
running or jumping. 3 Prolonged sitting or lying in one
position can lead to stiffness and flexion contractures.
4 This helps maintain muscle tone while providing
freedom of movement without weight-bearing on the
joints. 5 Prolonged sitting in one position can lead to
stiffness and flexion contractures.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Juvenile
Idiopathic Arthritis, Nursing Care
286. 2 The exercises are done to preserve joint function.
1 Exercises do not necessarily relieve pain. 3 Circulation
is not affected by the arthritic process. 4 Exercising does
not affect the subcutaneous nodules.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 33, Juvenile Idiopathic Arthritis, Nursing Care
 766 CHAPTER 35 Child Health Nursing
287. 1 Preadolescence is a critical period of growth, and
CHILD HEALTH NURSING
steroids could lead to growth retardation.
2 The effect of steroids on sexuality is unclear.
3 Although mood changes have been documented, this
is not the reason why steroids are avoided during
preadolescence. 4 Impaired body image is a result of
many variables, not just medications.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Assessment/Analysis; Reference:
ANSWERS AND RATIONALES
Ch 33, Juvenile Idiopathic Arthritis, Data Base
288. 1 Teaching methods in each age group are different
depending on the children’s cognitive ability;
individual differences depend on a variety of
factors, including intelligence and emotional status.
The child’s readiness to learn must be assessed
before developing a teaching plan that will bring
success.
2, 3, 4 This will be important later, but not initially.
Client Need: Health Promotion and Maintenance; Cognitive
rs
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Assessment/Analysis; Reference: Ch 29, Growth
and Development of the Child, Principles of Growth
289. 1 Helping families understand their feelings about
diabetes is essential in assisting them to develop
positive attitudes; these attitudes will motivate
them to achieve optimal control of the disease and
promote a healthy lifestyle for the child.
nu
l_
2 The child should participate in age-appropriate
activities; adequate exercise is an important part of the
treatment regimen for children who have diabetes.
3 This is important; however, if feelings are not
ca
addressed first, compliance with glucose monitoring is
less likely. Also, the age and developmental level of the
child must be considered before teaching can begin.
4 This is important; however, if feelings are not
i
addressed first, compliance with insulin administration
in
is less likely. Also, the age and developmental level
of the child must be considered before teaching can
begin.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
cl
Integrated Process: Caring; Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 33, Diabetes Mellitus,
Nursing Care
@
290. 2 Novolin N is an intermediate acting insulin; its peak
action is 4 to 12 hours.
1, 4 The peak action of Novolin N insulin is 4 to 12
hours; this is too late. 3 This is the peak time for regular
insulin, not Novolin N insulin.
Client Need: Pharmacological and Parenteral Therapies; Integrated
Process; Teaching/Learning; Cognitive Level: Comprehension;
Nursing Process: Evaluation/Outcomes; Reference: Ch 33,
Diabetes Mellitus, Nursing Care
291. 4 A bedtime snack is needed for the evening. Novolin
N insulin is intermediate-acting insulin, which
peaks 4 to 12 hours later and lasts for 18 to 24
hours. Protein and carbohydrate ingestion before
sleep prevents hypoglycemia during the night when
the Novolin N is still active.
1 The snack is important for diet/insulin balance during
the night, not encouragement. 2 There are no data to
indicate such a need; a bedtime snack is routinely
provided to help cover intermediate-acting insulin during
sleep. 3 The snack must contain mainly protein-rich
foods, not simple carbohydrates, to help cover the
intermediate-acting insulin during sleep.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 33, Diabetes Mellitus, Nursing Care
292. 3 An 8-year-old child is in the stage of industry
vs inferiority and strives to complete assigned
tasks.
1 This is true of an older child (adolescent). 2 Peer
g
influences increase as the child enters the preadolescent
and adolescent years. 4 This stage occurs during
in
adolescence.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Assessment/Analysis; Reference: Ch 33, Growth
and Development, Developmental Timetable
293. 3 An adolescent with type 1 diabetes must carry a
source of simple sugar (e.g., glucose tablets,
Insta-Glucose, sugar-containing candy such as Life
Savers) to rapidly counteract the effects of
hypoglycemia. This should be followed by a
complex carbohydrate and a protein.
1 This is an unrealistic and unnatural pattern for an
adolescent. 2 This is an unnecessary and time-
consuming procedure. 4 The adolescent should be made
to feel a part of the family; the recommended diet is
nutritious and no different from that of the rest of the
family. The timing of when food is eaten in relation to
insulin administration is important.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Diabetes
Mellitus, Nursing Care
294. 4 A blood glucose level of 180 mg/dL is above the
average range, and the prescribed rapid acting
insulin, is needed.
1 Although exercise does decrease insulin requirements
and does lower blood glucose levels, the immediate
action of insulin is needed. 2 This action will not
correct the problem; the blood glucose level is already
known. 3 Food intake at this time will increase the level
of blood glucose.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 33, Diabetes Mellitus, Nursing Care
295. 2 The adolescent needs immediate and easily
absorbable glucose, such as soda, and long-lasting
complex carbohydrates and protein, which are
supplied by the bun and hamburger.
1 This can be done after some glucose has been ingested;
otherwise, the adolescent’s hypoglycemia can become
severe. 3 Extra insulin will further aggravate the
problem. 4 This is unsafe; appropriate intervention is
necessary.

Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Diabetes
Mellitus, Data Base
296. 1 By increasing the caloric intake, thereby increasing
the protein and carbohydrate intake, a
hypoglycemic reaction caused by exercise is less
likely to occur.
2 An oral hypoglycemic is an inappropriate treatment
for individuals with type 1 diabetes. 3 This will not
prevent a hypoglycemic reaction when the child exercises
more vigorously than usual. 4 This type of intake is less
effective than other nutrients, such as protein, that are
absorbed more slowly and provide a more consistent
blood glucose level.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Diabetes
Mellitus, Nursing Care
297. 3 The white dots are nits, the eggs of head lice
rs
(Pediculosis capitis); they can be seen on the shaft of
hair along the scalp line, behind the ears, and at the
nape of the neck.
the presence of nits. 2 Canine ear mites are not
nu
1 This is too vague; objective visualization will confirm
transferable to humans. 4 This is a sign of scabies,
which is the Sarcoptes scabiei mite.
Client Need: Safety and Infection Control; Cognitive Level:
l_
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 33, Pediculosis
Capitis, Data Base
298. 4 Rheumatic fever is an inflammatory disease
ca
involving the joints, heart, central nervous system
(CNS), and subcutaneous tissue. It is thought to be
an autoimmune process that causes connective
tissue damage.
i
1 Tetanus is not caused by a streptococcal infection.
in
2 The disorder described is not influenza. 3 The
disorder described is not scarlet fever.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
cl
Process: Assessment/Analysis; Reference: Ch 33, Rheumatic Fever,
Data Base
299. 2 The purpose of digoxin (Lanoxin) is to slow and
@
strengthen the apical rate. The apical rate for a
healthy child of 5 years is 70 to 110 beats/min. If
the apical rate is slow, administration of the drug
may lower the apical rate to an unsafe level. Many
health care providers set individual parameters to
be followed.
1 This rate is too far below that which necessitates
withholding digoxin for children; it is the correct rate for
withholding digoxin in adults. 3, 4 This is within the
expected heart rate range of 5-year-old children and does
not necessitate withholding digoxin.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 29, Characteristics of Growth, Circulatory
System
Answers and Rationales 767
300. 2 Factor VIII has a short half-life; therefore,
CHILD HEALTH NURSING
prophylactic treatment involves administering the
factor on the scheduled days in the morning so that
the child will get the most benefit during the day
when most active.
1 Prophylactic treatment is done on a scheduled basis
to prevent a bleed from occurring. 3 Administering
the drug at bedtime will limit its effectiveness, since
bleeds are more common when the child is active.
4 This does not take into consideration the properties
ANSWERS AND RATIONALES
of the drug.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 33,
g
Hemophilia, Nursing Care
301. 3 Factor VIII is the missing plasma component
in
necessary to control bleeding in a child with
hemophilia A.
1, 4 Factor VIII, the missing component, is not
provided by this blood derivative. 2 Although fresh
frozen plasma does contain factor VIII, there is an
insufficient amount in a plasma transfusion; a higher
volume is required.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Knowledge; Nursing Process: Planning/Implementation;
Reference: Ch 33, Hemophilia, Data Base
302. 2 The hemophilia gene is carried on the X
chromosome but is recessive. Therefore, the female
is the carrier (an unaffected XO and an affected XH).
If the male receives the affected XH (XHYO), the
disorder is manifested.
1 Hemophilia is carried by the female; the Mendelian
laws of inheritance are not sex-specific. 3 Hemophilia is
a sex-linked recessive disorder. 4 Females only carry the
trait; males usually are affected.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 33, Hemophilia, Data Base
303. 3 Aspirin has an anticoagulant effect, and it may
harm a child with bleeding problems; in addition,
aspirin is contraindicated for all children because of
its relationship to Reye syndrome.
1 This response does not answer the mother’s question;
it may cause the mother to feel defensive. 2 Aspirin is
contraindicated because of its anticoagulant effect.
4 Acetaminophen cannot prevent bleeding episodes;
it is an analgesic.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 33,
Hemophilia, Nursing Care
304. Answer: 1, 3, 5.
1 Children with Down syndrome have a broad
nose with a depressed bridge (saddle nose).
2 Children with Down syndrome have broad, short,
stubby hands and feet. 3 Children with Down
syndrome have inner epicanthic folds and oblique
palpebral fissures; they also have speckling of the iris
(Brushfield spots). 4 Children with Down syndrome
 768 CHAPTER 35 Child Health Nursing

have hypotonic, not hypertonic, musculature. the duration prescribed. This information should be
CHILD HEALTH NURSING

5 Children with Down syndrome have a transverse
palmar crease (simian crease) formed by fusion of the
proximal and distal palmar creases.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 30,
Trisomy 21, Data Base
305. 1 A wheelchair must be used when there is an order
for non-weight-bearing activity; a transfer using the
unaffected leg prevents weight-bearing on the
ANSWERS AND RATIONALES
communicated to the health care provider for
evaluation.
1 The prescription is for administration every 3 hours;
legally it can be given only within these guidelines.
2 There are no data to support this; the amount of
medication was probably inadequate for the adolescent’s
pain tolerance level. 3 The nurse should not ignore the
adolescent’s need for pain relief.
Client Need: Management of Care; Cognitive Level: Analysis;

affected leg. Integrated Process: Communication/Documentation; Nursing

2 Kneeling applies pressure to the acetabulum and is Process: Planning/Implementation; Reference: Ch 29, Age-Related
considered a weight-bearing activity; it is contraindicated. Responses to Pain, Nursing Care Related to Pain Assessment
3 Range-of-motion exercises are contraindicated; an 308. Answer: 5 mL. For a 500 mL bag, 10 mEq of potassium

g
abduction brace is to be used 23 hours a day; the other chloride is needed to equal a concentration of
hour is for bathing and toileting. 4 Using a four-point 20 mEq/L. Use the “Desired over Have” formula of

in
gait with crutches equally distributes the weight-bearing ratio and proportion to solve this problem.
to all four extremities.
Desired 10 mg x mL
Client Need: Basic Care and Comfort; Cognitive Level: =
Application; Integrated Process: Teaching/Learning; Nursing Have 2 mg 1 mL

rs
Process: Planning/Implementation; Reference: Ch 33, Legg-Calvé- 2 x = 10
Perthes Disease, Nursing Care x = 10 ÷ 2
x = 5 mL

Nursing Care of Adolescents

306. The ball of the oxygen flowmeter should be set at 8 to

deliver 40% oxygen when using the Venturi mask.
nu Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 29, Principles Related to Medications for Children,
Nursing Care
309. 2 Anger interferes with communication; recognition
l_
and ventilation of anger help to resolve it and can
help increase productive communication.
1 Anger is interfering with the acceptance of
ca

responsibility and must be addressed first. 3 They are

too angry with each other to work this out alone; they
15 may continue to express anger toward each other, which
probably will escalate the conflict in their relationship.
i

4 The parent should be involved with the therapy and

therefore must be present when treatment is discussed.
in

10
Client Need: Psychosocial Integrity; Cognitive Level: Analysis;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 34,
5
cl

Hospitalization of Adolescents, General Nursing Care of Adolescents

310. 3 The menarche occurs when the prepubertal growth
1 spurt is almost completed and after the primary
and secondary sexual characteristics are almost
@

fully developed.
1 Pubic hair is apparent about 6 months after the breasts
begin to develop and before menarche occurs. 2 The
breasts are the first secondary sexual characteristics to
develop early during the prepubertal growth and
en S development period. 4 Although there may be a familial
hu
Op

tendency to reach the menarche at the same age, there

t

OXYGEN
Flo
w meter
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 30, Respiratory Tract Infections, Nursing Care
307. 4 The nurse made the assessment that the medication
was ineffective in relieving the adolescent’s pain for
are too many variables to use this as a guideline.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 34,
Growth and Development, Developmental Timetable
311. Answer: 75th percentile. Find the age of 13 along the
horizontal scale at the bottom of the graph. Follow
the line vertically up the graph to the student’s BMI of
 Answers and Rationales 769

21. The two lines bifurcate on the line for the 75th Client Need: Pharmacological and Parenteral Therapies; Cognitive

CHILD HEALTH NURSING

percentile.
Client Need: Basic Care and Comfort; Cognitive
Level: Application; Nursing Process: Planning/
Implementation; Reference: Ch 33, Obesity, Nursing
Care
312. 1 A side effect of vinCRIStine is alopecia. To
adolescents, who are very concerned with identity,
this represents a tremendous threat to their
self-image.
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 34,
Bone Tumors, Nursing Care
313. 3 Several meetings with an adolescent provide an
opportunity to develop trust and establish a
relationship.
1 This is not necessary and may not help in establishing
a relationship. 2 This is not realistic because the nurse is
not the teenager’s peer. 4 It is not necessary to
communicate in concrete terms because the average

ANSWERS AND RATIONALES

2 Constipation, although very serious, is not as
important to the adolescent as a side effect that affects
appearance. 3 Although anorexia will be a concern while
undergoing chemotherapy, it is not as important before
adolescent is past this cognitive level.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Communication/Documentation;

g
Nursing Process: Planning/Implementation; Reference: Ch 34,
the start of the regimen. 4 Although neurologic side Hospitalization of Adolescents, General Nursing Care of Adolescents
effects are serious, they are not as important to the 314. 3 The future seems far away; immediate gratification

in
adolescent before the start of chemotherapy. takes priority.

rs
BMI BMI

34

nu
Body mass index–for-age percentiles:
Girls, 2 to 20 years
97th

34
l_
32 95th 32

30 30
ca

90th
28 28

85th
i

26 26
in

75th
24 24
cl

22 22
50th

20
@

20
25th

10th
18 5th 18
3rd

16 16

14 14

12 12

kg/m2 kg/m2

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Age (years)
 770 CHAPTER 35 Child Health Nursing
1 Adolescents are often confused about their feelings.
CHILD HEALTH NURSING
2 School-age children (7 to 11 years) use concrete
operational reasoning; adolescents are learning to think
in abstract terms and use formal operational reasoning.
4 This is the developmental stage of children 6 to 12
years of age; identity versus role confusion is the
developmental stage of the adolescent.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 34, Growth and Development, Developmental
ANSWERS AND RATIONALES
Timetable
315. 4 The hypothalamic-pituitary-gonadal-adrenal
mechanism is responsible for the physiologic and
structural changes that occur at puberty. In girls the
adrenal glands secrete androgens that are
responsible for the appearance of axillary and
pubic hair.
1 This is not an indicator of sexual maturity. 2 This is
not a reliable indicator of sexual maturity. 3 Menarche
usually occurs about 2 years after initial pubescent
rs
changes; ovulation usually begins within a year after the
first menstrual period.
Client Need: Health Promotion and Maintenance; Cognitive
Growth and Development, Developmental Timetable
316. 2 Adolescents are concerned about body image and nu
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 34,
fitting in with a peer group; the stabilizing rod may
l_
be viewed as an insult to the intactness of the body.
The nurse should obtain additional information to
confirm this assumption.
1 Weight-bearing can be prevented with crutches, which
ca
provide greater mobility than a wheelchair. 3 After open
reduction and internal fixation with a rod insertion,
adolescents generally return to activities after several
months. 4 Although pain may be a concern, an
i
adolescent is old enough to understand that analgesics
in
are available; this probably is not the reason the
adolescent is upset.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
cl
Reference: Ch 34, Hospitalization of Adolescents, Data Base
317. 3 The hyperextension required in swimming aids in
strengthening back muscles and increases deeper
@
respirations, both of which are necessary before
surgery and/or before wearing a brace or cast.
1, 2, 4 This involves twisting the back muscles, which is
not therapeutic for a child with this condition.
Client Need: Basic Care and Comfort; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 34, Scoliosis,
Nursing Care
318. 1 Continuing growth causes changes in muscle, bone
structure, and position. The brace is worn for 6
months after physical maturity, which is confirmed
by radiographic examination showing cessation of
bone growth.
2 The brace is used to halt the progression of the
curvature, not correct it. 3 This is not an appropriate
criterion for removal of the brace. 4 Pain is not usually
a symptom of scoliosis.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 34,
Scoliosis, Data Base
319. Answer: 1, 2, 5.
1 A soft-tipped applicator should be used to reduce
trauma to the oral mucosa. 2 This allows the fluid to
bypass the sores in the mouth and may be less irritating
to the mucosa; it provides for comfort. 3 This will
injure the oral mucosa and should be avoided. 4 This
may irritate the oral mucosa and should be avoided; if
prescribed, it should be diluted. 5 Extremes in
g
temperature may injure the oral mucosa and cause
discomfort.
in
Client Need: Safety and Infection Control; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 34, Bone
Tumors, Nursing Care
320. 3 Establishing an identity is the major developmental
task of the adolescent; to achieve this task, there is
a need to conform to group norms that include
appearance and acceptance. Appealing to this need
may achieve more success than other teaching
strategies.
1 This teaching strategy may be successful with an older,
more secure group of people. 2 Adolescents tend to
believe that they are invincible and probably will not
relate to this teaching strategy. They are also concerned
about the present, not the future. 4 Because adolescents
believe they are invincible, they would not relate to this
teaching strategy.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 34,
Growth and Development, Developmental Timetable
321. 4 Because adolescents have a developmental need to
conform to their peers, the adolescent should be
able to select a bracelet with a similar configuration
to those worn by peers.
1 Hiding the bracelet under long-sleeved clothes might
be acceptable in cool weather, but not when it is warm
and friends are wearing T-shirts. 2 The bracelet should
be worn at all times when not with responsible family
members. The rules of contact sports may not permit the
players to wear jewelry that could harm themselves or
others. 3 This is unrealistic, especially if the adolescent
does not want to tell friends why the bracelet is needed.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Teaching/Learning;
Nursing Process: Planning/Implementation; Reference:
Ch 34, Hospitalization of Adolescents, General Nursing Care of
Adolescents
322. 1 Although the adolescent should be told that this is
a common occurrence at this age, to relieve his
anxiety he should be helped to understand and
expect both this and other changes that occur
during puberty.

2, 4 This response may increase the adolescent’s anxiety
because it implies that he has a problem. 3 This
response is not sensitive to the adolescent’s concern; it
does not offer follow-up discussion, education, or
counseling.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Caring; Nursing Process:
Planning/Implementation; Reference: Ch 34, Growth and
Development, Developmental Timetable
323. 1 Tinnitus in adolescents is usually related to hearing
loud music, especially via headphones.
2 Long-resolved ear infections usually have no sequelae,
such as buzzing in the ears. 3 Tinnitus is a concrete
occurrence; it is doubtful that it will emerge when there
is emotional trauma. 4 Familial deafness is not related
to the recent development of an adolescent’s tinnitus.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 31, Hearing Impairment, Data Base
324. 3 Passing the high school equivalency test is
rs
the client’s desire, and the nurse should do
everything possible to assist the client to achieve
the goal.
nu
1 This response is not therapeutic; the client has an
unmet need, and the nurse should not try to refocus the
client away from the stated objective. 2 The client
l_
i ca
in
cl
@
Answers and Rationales 771
should be encouraged, not discouraged; mental activity is
CHILD HEALTH NURSING
not too taxing and is not unrealistic if the client wishes
to do it. 4 There are no data that support the
conclusion that the client needs to work through feelings
about the illness.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Caring; Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 34,
Hospitalization of Adolescents, General Nursing Care of Adolescents
325. 1 Albuterol (Proventil) relaxes smooth muscles in the
respiratory tract, resulting in bronchodilation. The
ANSWERS AND RATIONALES
priority is to facilitate respirations. This intervention
follows the ABCs of emergency care—Airway,
Breathing, Circulation.
g
2 This is not the priority. The results will not influence
the priority intervention. 3 This is not the priority.
in
Chest physiotherapy is performed after the respiratory
airways are opened. In many facilities, chest
physiotherapy is the responsibility of the nurse, not a
respiratory therapist. 4 The use of an incentive
spirometer can be taught after the acute episode of
respiratory distress. It will take time to receive the device
and teach the adolescent.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 32,
Asthma, Nursing Care
 THANK YOU 👍

CLICK HERE- https://t.me/Clinical_Nursing