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

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

 

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

Chapter 2: Standards of Practice/Ethical Considerations

 

 

 

Multiple Choice

 

 

 

  1. Leah is a new graduate nurse and has questions about her scope of practice. The best place to review would be:
  2. The code of ethics.
  3. The standards of practice and professional performance.
  4. The NCLEX exam.
  5. The state licensing body.

 

ANS: 2

  Feedback
1. Applies to the accountability and protection for the public
2. Benchmark for quality and accountability to provide professional guidance
3. This is the basic exam, but it does not give guidance on this matter.
4. The state has rules and regulations, but it is not the source for overall professional accountability and guidance.

KEY: Content Area: Professionalism | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. The Code of Ethics for Nurses is characterized by all of the following except:
  2. It serves as a guide to empower individuals.
  3. It upholds ethics, principles, rights, duties and virtues.
  4. It is a private statement for nurses only.
  5. It is a public statement for nurses and their patients.

 

ANS: 3

  Feedback
1. Part of the Code of Ethics
2. Part of the Code of Ethics
3. The Code of Ethics is not a private statement. It is for the public and nurses.
4. Part of the Code of Ethics

KEY: Content Area: Professionalism | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A nurse has discussed the plan of care, asked for parental input, and has spoken with the doctor about the needs of the family and patient. This nurse is exhibiting which characteristics of therapeutic relationships in pediatric medicine?
  2. Goals, mutual respect/trust, and advocacy
  3. Empowerment, sympathy, and empathy
  4. Goals, advocacy, and sympathy
  5. Respect/trust, disengagement, and sympathy

 

ANS: 1

  Feedback
1. The nurse is demonstrating all characteristics listed.
2. The nurse is not demonstrating sympathy or empathy for the patient.
3. The nurse is not demonstrating sympathy for this family.
4. The nurse is not disengaging or providing sympathy for the family.

KEY: Content Area: Therapeutic Communication | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A primary source for the standards of practice for pediatric nurses is:
  2. Pediatric Nursing Scope and Standards of Practice.
  3. Code of Ethics.
  4. Nightingale’s Pledge.
  5. None of the above.

 

ANS: 1

  Feedback
1. Reflects key themes and trends that are relevant to our time and to all pediatric health care settings, which provide the framework for the emergence of specific standards.
2. The Code of Ethics in Nursing provides a foundation for nurses and empowers them as well.
3. The pledge was part of the early Hippocratic Oath.
4. One answer is correct.

KEY: Content Area: Professionalism | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Sarah is a 4-year-old patient with cystic fibrosis. She has been having increased hospitalizations and prefers to have Leah as her nurse as an inpatient. Leah has been assigned to care for a different set of patients today, yet Sarah’s mother insists on having Leah as their nurse. Which action would be best for Leah to take with Sarah and her mother?
  2. Ignore the situation.
  3. Speak to Sarah and her mother to discuss the importance of having another nurse, who also knows the case, care for her.
  4. Let Sarah’s mother and Sarah voice their reasoning for wanting Leah, and then explain the need for Leah to have a different assignment.
  5. Let the charge nurse deal with the situation.

 

ANS: 3

  Feedback
1. Ignoring the situation does not demonstrate therapeutic communication.
2. Speaking with the family is important, but letting the family voice their concerns is important as well.
3. The dialogue between the patient and nurse can enhance trust and understanding so the patient can understand the situation.
4. The charge nurse may be part of the conversation, but it is important for Leah to speak too.

KEY: Content Area: Therapeutic Interactions | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Analysis | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which of the following situations would be considered a therapeutic communication challenge in pediatric nursing?
  2. A street-smart teenager
  3. A noncompliant patient and family
  4. A culture that the nurse has not been previously exposed to
  5. All of the above

 

ANS: 4

  Feedback
1. Considered a therapeutic communication challenge in pediatric nursing
2. Considered a therapeutic communication challenge in pediatric nursing
3. Considered a therapeutic communication challenge in pediatric nursing
4. All fit the criteria

KEY: Content Area: Therapeutic Communication | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. The purpose of a Child Life Department for Family-Centered Care is:
  2. To prepare the child for procedures.
  3. To offer time to be a “kid”.
  4. To provide the staff with information about child development.
  5. To be the liaison between the hospital and the school system for a child.
  6. 1, 2, 4

 

ANS: 5

  Feedback
1. Preparation is an important element in caring for a child. It helps reduce anxiety and promotes a trusting relationship.
2. Playtime allows a child to cope and fosters self-expression, which reduces stress.
3. CLD is knowledgeable in child development and is present to support the child and the family, not the staff.
4. CLD provides a working relationship between the hospital and school for patients who are in the hospital long term.
5. Preparation is an important element in caring for a child. It helps reduce anxiety and promotes a trusting relationship. Playtime allows a child to cope and fosters self-expression, which reduces stress. CLD provides a working relationship between the hospital and school for patients who are in the hospital long term.

KEY: Content Area: Multidisciplinary Care | Integrated Processes: Caring | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A nurse is discussing pain management of a 3 year-old with the parents. An important factor the nurse should mention is:
  2. “A child is like a mini-adult, so they cope with pain the same way.”
  3. “Effective pain management for a child may require pharmacological and non-pharmacological methods.”
  4. “Children use the pain scale of 0-10.”
  5. “Pain is subjective, and all children cry when they are in pain.”

 

ANS: 2

  Feedback
1. Children have a unique response to pain.
2. Pharmacological methods may work for children, but using non-pharmacological methods, such as distraction, are also beneficial.
3. Common pain scales for children consist of the FLACC and NAP.
4. Pain is subjective, but not all children will cry. Some will be irritable or withdrawn.

KEY: Content Area: Pain | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive: Level: Synthesis | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A 6-year-old boy is to receive a dose of morphine to aid in pain management after an open appendectomy. The nurse knows the correct dose for the morphine is calculated based on:
  2. Age.
  3. Height.
  4. Body weight.
  5. All of the above.

 

ANS: 3

  Feedback
1. Age is not a factor in drug calculation.
2. Height is not a factor in drug calculation.
3. Body weight is used for drug calculation.
4. Age and height do not affect drug calculation.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A nurse at the clinic is teaching a new mother how to give Tylenol drops to her infant. The nurse knows that the mother has an understanding of medication administration when the mother states:
  2. “I will give the medication as prescribed and use a teaspoon to measure the correct amount.”
  3. “I will use a syringe to measure the correct amount and place the syringe in the side of his cheek to take the medicine.”
  4. “I will measure the medication in a cup and place it into the bottle.”
  5. “I will make sure he only takes the medicine until he acts like he feels better.”

 

ANS: 2

  Feedback
1. A teaspoon does not give an accurate measurement for children’s medication.
2. A syringe is the best option for medication administration. Placing it in the side of the cheek enables the infant to swallow without choking.
3. This method does not ensure that the child received all the medication, especially if the entire bottle is not consumed.
4. Medication should be taken for as long as the doctor has ordered.

KEY: Content Area: Pharmacology | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. The public health nurse is working on new printed material for the pediatric clinic. The public health nurse decides more education needs to be provided on nutritious snacks for children 5 to 10 years of age. In the design process of the pamphlets, it is important for the public health nurse to:
  2. Provide information at an educational level no higher than 8th grade.
  3. Provide information at an education level no higher than 12th grade.
  4. Provide the material in an easy manner, using acronyms to keep the pamphlet small.
  5. Provide information in small print and place the pamphlet in open areas for people to take freely.

 

ANS: 1

  Feedback
1. Information should be at the 8th grade level or lower.
2. Information should be at 8th grade level or lower.
3. Acronyms may give different ideas than what the material is stating.
4. Allowing for people to take freely is good, but small print can deter someone from reading the information. Bold and bright print is best.

KEY: Content Area: Education | Integrated Processes: Teaching/Learning | Client Need: Health Promotion | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A pediatric clinic nurse’s main responsibilities include:
  2. Assessing parenting styles.
  3. Assessing readiness to learn for the patient and family.
  4. Documentation of family and parental responses to education.
  5. Assessing the culture of the family.
  6. All of the above.
  7. None of the above.

 

ANS: 5

  Feedback
1. It is a responsibility along with others.
2. It is a responsibility along with others.
3. It is a responsibility along with others.
4. It is a responsibility along with others.
5. Correct because all are responsibilities of the nurse.
6. One answer is correct.

KEY: Content Area: Education | Integrated Processes: Teaching/Learning | Client Need: Health Promotion | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Grant, who is 16, is at the pediatric clinic for his yearly checkup. The nurse requests that his father step out of the patient room because:
  2. Grant’s father is not providing information the nurse needs.
  3. Grant appears apprehensive with his father in the room.
  4. Grant has a right to confidentiality to discuss his use of alcohol.
  5. Privacy is not appropriate for this age range, and the father should remain in the room.

 

ANS: 3

  Feedback
1. Confidentiality is appropriate due to Grant’s age.
2. The question does not give information about the interaction between Grant and his father.
3. Privacy about topics such as substance use is appropriate for this age range.
4. Grant has a right to confidentiality due to his age.

KEY: Content Area: Privacy/Confidentiality | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A medical chaperone is advisable for a 14-year-old girl when:
  2. Having an exam of the breasts.
  3. Having an eye exam.
  4. Having a hearing screen.
  5. Having her height and weight taken.

 

ANS: 1

  Feedback
1. A medical chaperone should be present because of the invasiveness of the procedure.
2. A medical chaperone is recommended, but not a necessity.
3. A medical chaperone is recommended, but not a necessity.
4. A medical chaperone is recommended, but not a necessity.

KEY: Content Area: Growth and Development | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A 9-year-old has come to the nurse’s office at the school complaining of arm pain. The nurse examines the arm and notices fingertip bruises on the forearm, as if it has been squeezed tightly. The nurse talks to the child about how the arm got the bruises. The next action the school nurse should take is:
  2. Report this to the classroom teacher, principal, and Child Protective Services since it is a questionable mark on the forearm.
  3. Let the child go back to the classroom since this is a normal bruising pattern that children get at this age through play.
  4. Let the child go back to the classroom since the child explains that the bruises came from a game of tag.
  5. Document the bruising and follow up with the child in two days to make sure it is healing.

 

ANS: 1

  Feedback
1. The nurse is a mandatory reporter and should speak with the people listed because bruising like this is abnormal for a child.
2. This is an abnormal bruising pattern for child.
3. Documentation and notification should occur because this is an abnormal bruising pattern for a child.
4. Documentation and notification should occur because this is an abnormal bruising pattern for a child.

KEY: Content Area: Abuse | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Ali is a new graduate nurse and has been working on the nursing unit for six months. Ali has noticed that the nurses’ station attempts to keep patient information confidential. Which of the following actions are not good practices for maintaining confidentiality?
  2. Placing the patient chart upside down on the desk when not in use so the name is not revealed.
  3. Speaking of patient’s by room number, not by name.
  4. Staying logged onto a computer to answer a call light.
  5. Removing patient identifiers on a medication bottle and throwing it into the garbage can.

 

ANS: 3

  Feedback
1. This is a good practice for confidentiality.
2. This is a good practice for confidentiality.
3. This allows for anyone to see the computer information about a patient, thus breaking confidentiality.
4. This is a good practice for confidentiality.

KEY: Content Area: Confidentiality | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. HIPAA requires health-care providers and employees to be cognizant of:
  2. Placement of computer screens to the public.
  3. Where discussions about patients occur.
  4. How and where change of shift reports occur.
  5. All of the above are areas to keep confidential.

 

ANS: 4

 

  Feedback
1. Follows HIPAA confidentiality along with others.
2. Follows HIPAA confidentiality along with others.
3. Follows HIPAA confidentiality along with others.
4. Computer screens, discussions, and change of shift reports should be kept confidential to follow HIPAA guidelines.

KEY: Content Area: Confidentiality | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Jake, a 14-year-old terminal leukemia patient, has told his parents and his health-care providers that he no longer wants to take chemotherapy treatments. The nurse knows that Jake:
  2. Can make this decision because he is of legal medical age.
  3. Is not of legal age to make a medical decision. This is an ethical decision that must be discussed only

with Jake’s parents.

  1. Must discuss this ethical issue with his parents.
  2. Is not of legal age to make a medical decision, thus he has not right to determine his care.

 

ANS: 3

  Feedback
1. Jake is not of legal age to make a medical decision, but he is of an age where he is aware of his body and the medical team’s actions.
2. Jake should be a part of the discussion because he is at an age where he is aware of his body and medical needs.
3. Jake and his parents should make the decision together.
4. Jake’s parents have medical power of attorney, but he is at an age where his wants and needs should be taken into consideration.

KEY: Content Area: Growth and Development | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Synthesis | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. JoJo, a 10-year-old patient in room 1232 with a right arm and leg amputation due to osteosarcoma, has been refusing help with his daily routine. JoJo is exhibiting:
  2. Beneficence.
  3. Justice.
  4. Veracity.
  5. Autonomy.

 

ANS: 4

  Feedback
1. This is an act for a nurse to do good, not harm a patient.
2. This is the obligation for caring for the patient.
3. This is the act of telling the patient the truth.
4. This is an act of exhibiting the need to do things by oneself.

KEY: Content Area: Growth and Development | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A home-care pediatric nurse is taking care of an immobile three year old with a home ventilator. The nurse knows she must maintain proper positioning for the child in order to prevent bedsores from developing. This knowledge is known as:
  2. Justice.
  3. Beneficence.
  4. Veracity.
  5. Fidelity.

 

ANS: 2

  Feedback
1. This is the obligation for caring for the patient.
2. This is an act for a nurse to do good, not harm a patient.
3. This is the act of telling the patient the truth.
4. This is a nurse’s responsibility for providing the best care possible for the patient.

KEY: Content Area: Professionalism | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Charlie is 17 years old. He comes to the ER because of a motor vehicle accident. The staff asks Charlie for the contact information for his guardian/parents in order to obtain informed consent for a procedure. Charlie states that he is an emancipated minor. The nurse knows this will mean:
  2. Charlie will require consent from a guardian prior to a procedure.
  3. Charlie will need the permission of the court prior to the procedure.
  4. Charlie is legally eligible to give consent because of his status.
  5. Consent is not needed in an emergency situation.

 

ANS: 3

  Feedback
1. Charlie’s situation would require consent if his parents/guardian were his legal guardians.
2. Charlie is at an age and legal status where he can make the decision by himself.
3. Charlie can give legal consent for treatment for himself because of his legal status.
4. Charlie is able to speak and make decisions in this situation, so he requires informed consent.

KEY: Content Area: Legal and Ethics | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Lynn is working as a preceptor with Jackie on a pediatric unit. Lynn knows that it is important to teach Jackie about the National Patient Safety Goals. This can be done by:
  2. Using the medical record number and date of birth as two personal identifiers prior to giving a medication.
  3. Using the medical record number and room number as two personal identifiers prior to giving blood products.
  4. Having the patient read from the patient ID band and state the room number.
  5. ID bands are not placed on children due to the choking hazard, so an ID band is not required.

 

ANS: 1

  Feedback
1. Safety in giving medication can be met with the date of birth and medical record number.
2. The medical record number is appropriate for safety, but room numbers change and are not a reliable identifier.
3. Verbalizing identifiers needs to be followed with reading the identifiers to maintain safety.
4. ID bands are placed on children. If it is a small child, it may be placed around the ankle.

KEY: Content Area: Legal and Ethics | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Preventing harm is a safety issue at any age in pediatric nursing. As a nurse, it is important to remember to do all of the following to prevent harm within the hospital except:
  2. Put crib rails in the highest position when an infant is in the bed.
  3. Place the IV monitor in a locked mode so if the child’s pushes the buttons, the monitor cannot change.
  4. Place formula in the microwave to heat thoroughly.
  5. Place a child safety tag on every child to prevent abduction.

 

ANS: 3

  Feedback
1. The highest and locked position is the safest for crib railings.
2. The locked mode is important so a child cannot change the settings.
3. Placing formula in a microwave can cause hot spots that are not identified when testing the formula prior to giving it to the child.
4. Children should have safety tags because this aids the staff in knowing when a child is in need.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. The pediatric floor has implemented the use of Humpty Dumpty Fall Prevention Program for its patients. The nurses know to use this tool to:
  2. Realize when a child is healthy and does not need to have fall monitoring.
  3. Make sure the entire staff recognizes the needs of each patient.
  4. Monitor a patient only after a patient has had a fall.
  5. Provide a basis for safety monitoring for pediatric patients.

 

ANS: 4

  Feedback
1. A fall assessment should be done on every child.
2. Only the nurse taking care of the patient needs to know. This is part of HIPAA and confidentiality.
3. The scale is a prevention mechanism and should be done prior to any chance of a fall.
4. This is a safety monitoring system for children.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Safety precautions for medication with the pediatric population include all of the following except:
  2. Reconciliation of medications from home and those given at the hospital.
  3. Using abbreviations to decrease confusion.
  4. Labeling syringes only if being taken to a patient’s room.
  5. All are correct.

 

ANS: 1

  Feedback
1. This is a safety precaution.
2. Abbreviation increases confusion and should not be used.
3. Syringes should be labeled at all times, not just for administration in the patient’s room.
4. All are not correct.

KEY: Content Area: Safety | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Shelly is a home-care pediatric nurse. Tonight she is taking care of Ellen. Ellen has a PICC line and requires IV antibiotics via a pump to be given during Shelly’s shift. Shelly knows the IV pump is used because:
  2. The pump can deliver medication faster through a PICC.
  3. The pump has built-in, customized software to prevent errors when delivering medications.
  4. The pump is not required. It is just a preference.
  5. The pump can tell Shelly when the medication has been completely delivered.

 

ANS: 2

  Feedback
1. An IV pump can deliver medication at a multitude of speeds. The delivery is not always fast through a PICC.
2. The built-in software provides safety in medication dosage.
3. The pump is required to be in this setting per the order.
4. Complete delivery of the medication is important, but not the top priority for this question.

KEY: Content Area: Safety | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. The Institute for Safe Medication Practices provides safety tools and resources for all except:
  2. The high-alert medications list.
  3. the error-prone abbreviations list.
  4. the do not crush list.
  5. the confusing drug names list.
  6. All of the above are part of the Safe Medication practice tools and resources.
  7. 1 and 4 are the main responsibilities of Safe Medication practice tools and resources.

 

ANS: 5

  Feedback
1. Is part of the ISMP along with other answers
2. Is part of the ISMP along with other answers
3. Is part of the ISMP along with other answers
4. Is part of the ISMP along with other answers
5. All statements are part of the ISMP
6. Is part of the ISMP along with other answers

KEY: Content Area: Safety | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Culture is known to be multidimensional. The nurse knows that culture includes:
  2. Poverty, religion, gender, and ethnicity.
  3. Ethnicity, poverty, religion, and language preferences.
  4. Religion and ethnicity.
  5. Religion, gender, and ethnicity.

 

ANS: 1

  Feedback
1. These are defined as the characteristics of culture.
2. Language preference is not necessarily a cultural component.
3. Culture consists of more than two entities.
4. Culture consists of more than these entities.

KEY: Content Area: Culture | Integrated Processes: Caring | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Judy, a pediatric nurse, is working a test trial for a new medication for type 1 diabetes. Judy knows she has a duty to not tell a lie. The truth-telling standard is known as:
  2. Benefice.
  3. Veracity.
  4. Advocacy.
  5. Fidelity.

 

ANS: 2

  Feedback
1. Does not meet the definition.
2. Telling the truth to the fullest degree is the definition.
3. The nurse is not advocating for anything.
4. Does not meet the definition.

KEY: Content Area: Safety | Integrated Processes: Caring | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Jenni is an 8-year-old girl with a known history of physical and sexual abuse. She has come to the pediatric clinic with her foster mother for a yearly physical. Which of the following statements would indicate that the nurse is prepared to work with the child?
  2. “Hi, Jenni. I am going to be your nurse today. Please put this gown on. I will chart on this computer, and then we will start with your assessment.”
  3. “Hi, Jenni. I am going to be your nurse today. Here is a gown for you to put on. I am going to step out of the room until you have it on. Please have your foster parent open the door when you are ready for me to come back in.”
  4. “Hi, Jenni. Please put the gown on, and then we will take you down the hall for your lab work.”
  5. “Hi, Jenni. We are going to get some tests done today to make sure you are healthy. The doctor is going to make sure there are no more marks on you today.”

 

ANS: 2

  Feedback
1. It is important to provide privacy for the child.
2. The nurse introduces herself, and then offers privacy to the child and foster parent to prepare for the exam.
3. Taking the child down the hall in a gown does not provide personal privacy. This should either be done before or after the exam.
4. A mention of marks may cause the child to have increased anxiety and feel as if she is doing something wrong.

KEY: Content Area: Abuse | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Munchausen’s by Proxy is a diagnosis given to the parent or caregiver of a child who is seeking self-recognition by stating a child has an unusual illness. This type of diagnosis for the parent/caregiver is known as:
  2. Child neglect.
  3. Medical abuse.
  4. Physical abuse.
  5. None of the above. The parent/caregiver is mentally ill.

 

ANS: 2

  Feedback
1. The caregiver is seeking care for the child, thus is not neglecting the basic needs.
2. The caregiver is using exaggerated symptoms.
3. There is no mention of harm or death.
4. One answer is correct.

KEY: Content Area: Abuse | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following are generally considered essential defining elements of a

profession?

  1. Code of Ethics
  2. PhD-level education
  3. International endorsement
  4. All of the above

 

 

ANS: 1

  Feedback
1. A code of ethics is a formal and public declaration of the principles of good conduct for members of a profession. It is one of the hallmarks of a profession.
2.  The degree is not required for basic entrance into the profession of nursing.
3. International endorsement does not meet the NCLEX standards of the United States.
4. Not all of the criteria is met with each example.

KEY: Content Area: Professionalism | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 2 | Type:

 

 

 

  1. Which, if any, of the following are true?
  2. The Florence Nightingale Pledge was the first official code of ethics for nursing.
  3. There are 17 provisions listed in the 2001 version of the Code of Ethics for Nurses.
  4. In order to be relevant and useful, the Code of Ethics for Nurses must be periodically reviewed and revised in terms of content, emphasis, language and format.
  5. All of the above

 

ANS: 3

  Feedback
1. The Nightingale Pledge was never “officially” adopted as a code of ethics, though many unofficially treated it as such. The code is a living document which must change with the times.
2. The Code of Ethics contains nine provisions.
3. Review and revision enable the Code of Ethics for Nurses to be relevant to the current practice standards.
4. Not all are true.

KEY: Content Area: Professionalism | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following are not provisions of the ANA Code of Ethics for Nurses?
  2. The nurse is responsible and accountable for individual nursing practices and determines the appropriate delegation of tasks, consistent with the nurse’s obligation to provide optimum patient care.
  3. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
  4. The nurse must not knowingly administer or permit the administration of any potentially deleterious substance without a duly authorized prescriber’s order and appropriate patient monitoring.
  5. All of the above

 

ANS: 3

  Feedback
1. This is a standard provision for nursing practice.
2. This is a standard provision of nursing practice.
3. Nursing responsibility is covered by more than one provision of the Code of Ethics for Nurses. It is not one provision.
4. Not all meet the provisional standards.

KEY: Content Area: Professionalism | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following standards of practice are applicable only to advanced practice nurses?
  2. Assessment
  3. Nursing diagnosis
  4. Outcomes identification
  5. None of the above

 

ANS: 4

  Feedback
1. Assessment is required of both registered and advanced practice nurses.
2. Registered and advanced practice nurses are able to create nursing diagnosis for a patient.
3. Registered and advanced practice nurses are able to identify outcomes for a patient.
4. Assessment, nursing diagnosis, and outcome identification are the responsibility of registered nurses at all levels of practice.

KEY: Content Area: Professionalism| Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following circumstances might incline a nurse to become disengaged or enmeshed rather than therapeutically engaged with a patient/family?
  2. 5-year-old child dying of cancer
  3. 6-month-old infant in a vegetative state, secondary to inflicted head injury
  4. Dying 10-day-old neonate with anencephaly whose parents do not visit
  5. All of the above

 

ANS: 4

  Feedback
1. The situation is emotionally charged in a manner that might incline a nurse to distance herself/himself from or become enmeshed with the child and/or the family.
2. The situation is emotionally charged in a manner that might incline a nurse to distance herself/himself from or become enmeshed with the child and/or the family.
3. The situation is emotionally charged in a manner that might incline a nurse to distance herself/himself from or become enmeshed with the child and/or the family.
4. Each of the situations is emotionally charged in a manner that might incline a nurse to distance herself/himself from or become enmeshed with the child and/or the family.

KEY: Content Area: Professionalism | Integrated Processes: Caring | Client Need: Psychosocial Integrity| Cognitive Level: Analysis | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following are not criteria for analyzing the propriety of nurse/patient interactions?
  2. The interaction is in keeping with objectives of the hospitalization.
  3. The interaction makes the patient/family happy.
  4. The interaction is consistent with the mission, vision, values of the hospital.
  5. None of the above

 

ANS: 2

  Feedback
1. Some interactions which make patients/families happy compromise the relationship and have a negative impact on colleagues and other patients/families.
2. Some interactions which make patients/families happy compromise the relationship and have a negative impact on colleagues and other patients/families. Some interactions that may be in the best interest of the child/family may not please them.
3. Some interactions which make patients/families happy compromise the relationship and have a negative impact on colleagues and other patients/families. Some interactions that may be in the best interest of the child/family may not please them.
4. Some interactions which make patients/families happy compromise the relationship and have a negative impact on colleagues and other patients/families. Some interactions that may be in the best interest of the child/family may not please them.

KEY: Content Area: Professionalism | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Conflicting communications from staff involved in the care of the child may contribute to challenging behaviors on the part of the child’s caretakers. Which, if any, of the following might contribute to conflicting communications?
  2. Shift and service rotations of staff during the course of the child’s stay
  3. Documentation deficits
  4. Diversity of communication styles and skills
  5. All of the above

 

ANS: 4

  Feedback
1. Numerous professionals with varying communication styles and abilities are involved in the care of the child, and they don’t always communicate adequately with each other verbally or in writing.
2. Numerous professionals with varying communication styles and abilities are involved in the care of the child, and they don’t always communicate adequately with each other verbally or in writing.
3. Numerous professionals with varying communication styles and abilities are involved in the care of the child, and they don’t always communicate adequately with each other verbally or in writing.
4. Numerous professionals with varying communication styles and abilities are involved in the care of the child, and they don’t always communicate adequately with each other verbally or in writing.

KEY: Content Area: Professionalism | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following are not good representations of family-centered care?
  2. The child’s caretakers are required to participate in medical rounds and nursing change-of-shift report
  3. Free or reduced cost food for breast-feeding mothers
  4. Staffed family resource and family learning centers
  5. All of the above

 

ANS: 1

  Feedback
  Parents/guardians should be encouraged but not required to participate in medical rounds and nursing change of shift (difference between family centered and family focused). They may not be able to be present or may be intimidated by or confused by rounds and prefer summaries afterwards.
  The cost of food is a physical need of the child.
  The staff plays a role in promoting family-centered care, but the statement does not state how this care is provided.
  Only one answer is correct.

KEY: Content Area: Psychosocial Development | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity| Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following is not true of pain management for children?
  2. Hypnotherapy and biofeedback, which are very useful with adults, are not generally effective with school-age and younger adolescents.
  3. Swaddling, non-nutritive sucking, and/or 24 percent sucrose solutions are often effective pain management interventions for neonates.
  4. Distraction can be effective pain management at the lower levels of the pain scale for infants/children of all ages.
  5. None of the above

 

ANS: 1

  Feedback
1. Hypnotherapy and biofeedback may be very effective pain management techniques and may be easier to teach children.
2. Swaddling, sucrose, and sucking are comfort measures for a neonate.
3. Distraction helps reduce the pain and can help a neonate cope with the pain.
4. One of the answers is correct.

KEY: Content Area: Physical and Psychosocial Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. According to the Joint Commission, medication reconciliation is required at which, if any, of the following points during a child’s hospital stay?
  2. Prior to performing an invasive procedure.
  3. Minimally, at admission, and weekly thereafter, and when changes are made in medication regimens
  4. When transferred from one division or service to another.
  5. All of the above

 

ANS: 3

  Feedback
1. An informed consent must be obtained prior to the invasive procedure.
2. Medication reconciliation should occur at least every 24 hours while an inpatient, discharge, and transfer.
3. Medication reconciliation is required at admission, discharge, and transfer of services/locations.
4. Only one answer is correct.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. In pediatric settings, which, if any, of the following are true of examination chaperones?
  2. They should only be offered if the child and the examiner are of different sexes.
  3. They are never needed when there is a parent present in the room during the exam.
  4. They are not a necessary precaution if the patient and family decline their presence, and their refusal is witnessed and documented in the medical record.
  5. None of the above

 

ANS: 4

  Feedback
1. A medical chaperone should be offered at all times for patient liability issues.
2. A medical chaperone may be needed when a parent is present to help ease anxiety and promote patient safety.
3. Chaperones are needed as a professional safety net to make sure the patient is safe. Hearsay cannot occur.
4. Chaperones are recommended during sensitive procedures and parts of an exam, regardless of the sex of the patient and examiner. They are usually not needed when a parent is present, but may be advisable when the parent has mental health deficits, cognitive impairment, or trust issues. If chaperones are refused, some situations call for modifying or deferring a particular exam or procedure.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, is not a practical impediment to care when a teen seeks confidentiality regarding diagnosis and treatment of a medical condition?
  2. Use of parent’s insurance
  3. Parental right to access child’s medical records
  4. Mature Minor Doctrine
  5. None of the above

 

ANS: 3

  Feedback
1. Parent’s insurance can be used, but they may find out the origin for the visit because of billing.
2. Parental rights may be deferred because of select issues.
3. The Mature Minor Doctrine allows a health-care provider to provide select care without the knowledge or consent of parents if the child demonstrates he/she meets the requirements of informed consent and the request is validated from the perspective of the provider. There may be other practical impediments nevertheless.
4. One answer is correct.

KEY: Content Area: Legal Issues | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which of the following, if any, are true about the nurse’s role in reporting child maltreatment to law enforcement or Child and Family Services?
  2. Any nurse having proof of abuse or neglect has a legal obligation to report or to confirm that a report has been made by family or another member of the health-care team.
  3. Any nurse having a reasonable suspicion that a child may be the victim of abuse or neglect has a legal obligation to report or to confirm that a report has been made by family or another member of the health-care team.
  4. Any nurse who makes a report in good faith cannot be convicted of a criminal or civil offense regardless of the outcome of the maltreatment investigation.
  5. All of the above

 

ANS: 4

  Feedback
1. A nurse is a mandatory reporter and needs to report any proof of evidence of abuse.
2. A nurse is a mandatory reporter. The nurse is required by law to report any suspicious activity or findings.
3. A nurse is a mandatory reporter. If suspicion is reported in good faith, then the nurse cannot be charged.
4. Nurses must report or confirm a report has been made if there is proof or reason to suspect that a child may be the victim of child abuse or neglect and are legally protected when making a report in good faith.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which of the following, if any, are not violations of HIPAA?
  2. Disclosing details about a child’s condition in response to questions asked by a nurse who cared for him/her on prior admissions and during this admission prior to transfer to your patient care setting.
  3. Disclosing details about a child’s condition in response to questions asked by family or friends calling with the code word selected by the parents and shared at their discretion.
  4. Disclosing details about a child’s condition in response to questions by a fellow nurse in your care setting who will not be assigned to the care of the child, will not be covering the child’s care while his nurses are busy, and is not the charge nurse.
  5. All of the above

 

ANS: 2

  Feedback
1. A patient’s information is disclosed on a need-to-care basis. If the nurse is not taking care of the child on the shift, then no information can be shared.
2. Disclosures without patient/family consent to those without a need to know (because they are involved in care directly or as a formal consultant, conducting authorized QI project or research, or are authorized to collect information for insurance/billing purposes) is a violation of HIPAA.
3. A nurse may not disclose any information about the patients other than on a need-to-know basis for caring for the patient directly.
4. One answer is correct.

KEY: Content Area: Safety and Legal Issues | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following is the correct definition of the ethics principle of “beneficence”?
  2. Fair distribution of resources
  3. The obligation to do things that are of benefit or for the good of the individual.
  4. The right to accept or refuse medical interventions according to one’s own values and priorities regardless of the potential outcome.
  5. None of the above

 

ANS: 2

  Feedback
1. Fair distribution focuses on the needs of the patient.
2. Beneficence is the duty to do good. Non-maleficence is the duty to do no harm. They are often combined: a duty to make sure the benefits outweigh the burdens (outcome-based or utilitarian approach to determining what is right).
3. Refusing care is a patient’s right and does not reflect on the duty of the nurse.
4. One answer is correct.

KEY: Content Area: Legal | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. When an 8-year-old patient is informed of his potential role in a medical research study (his parents having agreed to his participation), his agreement is termed:
  2. Consent.
  3. Permission.
  4. Assent.
  5. All of the above.

 

ANS: 3

  Feedback
1. The consent can only come from a person of legal age.
2. The child gave permission, but the informed consent given by the parents does not become permission.
3. This child has emerging capacity to make informed health-care decisions on his own behalf and should be involved, but does not have ultimate control. Parental permission is followed by child assent.
4. One answer is correct.

KEY: Content Area: Legal| Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which of the following, if any, are legitimate interventions for transitioning an adolescent to an autonomous adult health-care consumer?
  2. Involving the adolescent in providing some of his own medical history.
  3. Having the adolescent make his own appointments and make sure he doesn’t run out of his asthma medicines.
  4. Discussing the results of his laboratory tests with the adolescent before informing his parents.
  5. All of the above

 

ANS: 4

  Feedback
1. Appropriate care should allow for the adolescent to speak on his/her own behalf.
2. The adolescent is not of an age to make his/her own appointments. This is a required task of a legal guardian.
3. The information should be shared with the parents and the adolescent at the same time.
4. All of these are appropriate, but should be discussed with the adolescent and his parents before implementation. They need to know rationale and any limitations/backup plans.

KEY: Content Area: Legal | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which of the following has not been given priority by Joint Commission in their annual submissions of National Patient Safety Goals?
  2. Impaired professionals in the workplace
  3. Communication of stat laboratory results
  4. Hand hygiene
  5. All of the above

 

ANS: 1

  Feedback
1. Hand hygiene should be taken care of before and after patient contact, after contact with contaminated items, and after removal of gloves. Stat laboratory results should be returned to the doctor within specified times, and when reported by phone, should be written down and repeated back to the caller.
2. Stat laboratory results should be returned to the doctor within specified times, and when reported by phone, should be written down and repeated back to the caller.
3. Hand hygiene should be taken care of before and after patient contact, after contact with contaminated items, and after removal of gloves.
4. The impaired workplace is the correct language used by the Joint Commission for safety goals.

KEY: Content Area: Legal | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Two identifiers are required when providing patient care. Which, if any, of the following are not acceptable as one of the two?
  2. Medical record number
  3. Date of birth
  4. Room/bed number
  5. None of the above

 

ANS: 3

  Feedback
1. The medical record number is a permanently assigned number for the patient as long as they seek services.
2. The date of birth of an individual does not change.
3. Room/bed number is not a permanently assigned attribute in the health-care setting or for the life of the person. The patient for whom an intervention was ordered may have been moved or discharged since the order was placed and a new patient may now occupy the bed/room.
4. The room/bed number should not be used.

KEY: Content Area: Legal | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which of the following, if any, has structured a voluntary and confidential medication error reporting system that regularly publishes analyses and recommendations?
  2. Joint Commission
  3. The Food and Drug Administration (FDA)
  4. The Institute for Safe Medication Practices (ISMP)
  5. All of the above

 

ANS: 3

  Feedback
1. Gives guidelines, but no specific process.
2. Identifies risks of medications, not the process.
3. The Institute for Safe Medication Practices believes that we often learn best from the mistakes of others and publishes best practices that help avoid medication errors they post.
4. Only one choice is correct.

KEY: Content Area: Legal | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. A nurse loaning money to a patient/parent would likely be seen by most as a violation of which, if any, of the following?
  2. Beneficence Principle
  3. Professional Boundary
  4. Fidelity
  5. All of the above

 

ANS: 2

  Feedback
1. Lending of money may not be in the best interest of the patient/parent.
2. Presumably, the nurse wouldn’t do it for all patients/families. If small emergency loans are to be made, they shouldn’t come from an individual nurse, but from a managed fund that has rules attached and is anonymous. A nurse is a caring/nurturing professional, not a friend, a family member, or a banker (all of whom might, as part of their role, lend money). If one nurse does it, it generates expectations/pressures for other nurses.
3. The nurse did not promise to give money to the family.
4. Only one answer is correct.

KEY: Content Area: Legal Issues | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following is not required when contending that a minor child qualifies as a “mature minor” and, therefore, should be allowed to make a medical decision on his own behalf?
  2. He should not have been held back in any grade in school.
  3. He should be making his decision free of undue influence or pressure from someone else.
  4. He should be able to indicate the risks and benefits of the choice he is making.
  5. He should be able to give a reason for his choice.

ANS: 1

  Feedback
1. School performance is not a factor. He must be able to demonstrate that he is making an informed choice just as is required of adults.
2. Influences can pressure a person to make a medical decision and should be avoided if possible.
3. Verbalization of the risks is a developmental task for a minor.
4. Reasons for the choice are not required.

KEY: Content Area: Legal Issues | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following is a developmentally-based medication administration strategy for use by pediatric bedside nurses?
  2. Dilute the painful IM medication with Lidocaine rather than water or saline so that it doesn’t hurt as much when injected.
  3. The use of a sticker chart to reward taking medication promptly and without fuss.
  4. Calculate medication dosage based on milligrams per kilogram.
  5. None of the above

 

ANS: 2

  Feedback
1. Not a developmental strategy and can cause an increased risk for reaction from the patient. Diluting the medication with Lidocaine is not a developmental strategy. It should be used for all patients without allergy or other contr-aindication to Lidocaine if the medication burns/stings significantly.
2. The stick chart allows a child to have a visual to identify goal accomplishment.
3. Calculations should be done, but is not a developmental strategy for pain management. Most children’s medications are dosed on a milligram per kilogram basis, but this is a prescribing strategy and falls to the doctor (or the advanced practice nurse with prescriptive authority). It is based on growth and physiology, not development.
4. One answer is correct.

KEY: Content Area: Pain | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following would violate the Code of Ethics for Nurses?
  2. Deciding not to speak up and remind a rushed/forgetful physician to wash her hands before performing a quick/superficial patient exam.
  3. Remaining silent when concerned that the surgeon has given parents biased information as part of the informed consent/permission process for surgery on their child.
  4. Diluting the painful IM antibiotic with saline rather than Lidocaine so that a sexually active teen with STDs more fully experiences the consequences of her poor choices.
  5. All of the above

ANS: 4

  Feedback
1. Speaking up for patient safety is a priority for nurses.
2. Not providing accurate information to the patient is a violation of the Code of Ethics for Nurses.
3. Creating increased pain for a procedure is unethical for medical professionals.
4. A nurse is the advocate for the patient’s safety and well-being and should intervene in the first two scenarios. The third situation demonstrates a judgmental and punitive approach that does not reflect the nonjudgmental, compassionate respect a nurse should have for the dignity of the patient.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Choice

 

 

 

  1. Which, if any, of the following are ways in which toddlers do not differ from adults with respect to pain experience and management?
  2. Physiologic response to the manifestations of pain
  3. Ability to localize pain
  4. Response to pain medications
  5. None of the above

ANS: 4

  Feedback
1. A toddler will have manifestations with pain.
2. Toddlers can point to where an area hurts or may be pulling, rubbing, or avoiding areas that have pain.
3. Toddlers can have a positive response to pain medications.
4. Infants and toddlers differ from adults in all respects. These differences have implications for pain monitoring and for choice and dosage of pain medications.

KEY: Content Area: Physical and Psychosocial Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Choice

 

 

 

Multiple Response

 

 

 

  1. A nurse is assessing a post-operative 3-month-old patient. The nurse knows pain assessment for an infant differs from older children. She should be assessing for which of the following?
  2. Oxygen saturations
  3. Tachypnea
  4. Tachycardia
  5. Movement of extremities
  6. Parents’ response to the infant

ANS: 1, 2, 3, 4

  Feedback
1. Oxygen requirements indicate pain.
2. An increased rate of breathing is an indicator of pain.
3. Increased heart rate can indicate pain.
4. Lack of movement or crying with movement can indicate pain.
5. The parental response can comfort the child, but does not physically indicate pain.

KEY: Content Area: Pain | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Evaluation | REF: Chapter 2 | Type: Multiple Response

 

 

 

  1. Albert, a new nursing student, is given documentation to sign prior to his clinical experiences. The first document discusses confidentiality. An example of the need to keep confidentiality for a pediatric patient would be:
  2. A 15-year-old girl asking for birth control without parental consent.
  3. A 16 year-old boy discussing drug use with the nurse.
  4. A 12 year-old girl discussing peer pressure issues with the nurse.
  5. All of the above should be kept confidential.

ANS: 4

  Feedback
1. Confidentiality is needed for this patient along with other scenarios.
2. Confidentiality is needed for this patient along with other scenarios.
3. Confidentiality is needed for this patient along with other scenarios.
4. These topics require confidentiality and are not required to be communicated to parents/guardians without the patient’s permission.

KEY: Content Area: Confidentiality | Integrated Processes: Caring | Client Need: Health Promotion | Cognitive Level: Comprehension | REF: Chapter 2 | Type: Multiple Response

 

 

 

  1. Sally’s, an 11-year-old girl, was diagnosed with a brain tumor six months ago. The tumor has spread despite multiple attempts with radiation to stop the process. Sally’s parents have decided they want to stop radiation therapy and attempt alternative therapy. Which of the following would not be considered alternative medicine?
  2. Reiki
  3. Acupuncture
  4. Biofeedback
  5. Herbs
  6. Massage therapy

 

ANS: 1, 2, 3, 4, 5

  Feedback
1. Considered alternative medicine, along with others
2. Considered alternative medicine, along with others
3. Considered alternative medicine, along with others
4. Considered alternative medicine, along with others
5. Considered alternative medicine, along with others

KEY: Content Area: Alternative Therapy | Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Application | REF: Chapter 2 | Type: Multiple Response

 

 

 

True/False

 

 

 

  1. A neonatal intensive care nurse has been taking care of Shelley’s baby in the unit for the last eight weeks. The nurse has become friends with Shelley. The nurse befriends Shelley on a social networking site. This is a breach of professionalism.

ANS: T

  Feedback
1. The nurse has breached the friendly professionalism boundary by becoming a friend of Shelley’s on a social networking site while Shelley’s baby is still in the NICU.
2. The nurse has breached the friendly professionalism boundary by becoming a friend of Shelley’s on a social networking site while Shelley’s baby is still in the NICU.

KEY: Content Area: Therapeutic Communication | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 2 | Type: True/False

 

 

 

  1. Teenage parents can make medical decisions for their ill infant even though they (the teen parents) are not of a legal age.

ANS: F

  Feedback
1. Teenage parents cannot make medical decisions for their own child. The grandparents must make the medical decisions for the teenage parents.
2. Teenage parents cannot make medical decisions for their own child. The grandparents must make the medical decisions for the teenage parents.

KEY: Content Area: Legal and Ethics | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 2 | Type: True/ False

 

Chapter 10: Adolescents

 

 

 

Multiple Choice

 

 

 

  1. A mother and daughter are at the well-child clinic for the daughter’s yearly checkup. The daughter is concerned because she is of shorter stature than most of her friends. She asks the nurse if she will continue to grow like her friends. A question the nurse should ask the girl to identify if growth will continue is:
  2. “What was the date of your last menstrual cycle?”
  3. “At what age did you start menarche?”
  4. “What is the height of your mother?”
  5. “What type of food do you like to eat in a 24-hour period?”

 

ANS: 2

  Feedback
1. The date of the last menstrual cycle does not indicate the growth rate for the teen.
2. From the onset of the first menarche to the stopping of growth is 18 to 24 months.
3. Genetics can be part of the height, but it needs to be evaluated from both parents.
4. Nutrition is important, but not the main indication for the final height.

KEY: Content Area: Sexual Development | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A mother of a 16-year-old boy states that her son is sleeping all the time. The nurse knows that at this age, an adolescent tends to increase in all of the following areas except:
  2. Metabolism.
  3. Rapid growth.
  4. Staying up later at night.
  5. Academic requirements.

 

ANS: 4

  Feedback
1. Puberty is a time for increased metabolism because of the rate of growth for teen boys.
2. Rapids growth is occurring during this age.
3. Teens attempt to exert independence in choices and social aspects, such as staying up later at night.
4. Academic requirements are not as important as the social aspect for most teen boys.

KEY: Content Area: Growth | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Identify a characteristic of formal operations in a teenager.
  2. Believes that they are the center of the world
  3. Whatever I want, I get.
  4. Planning on attending a university after graduation
  5. Wants to feel accepted by the teachers

 

ANS: 3

  Feedback
1. A teen is beyond this thought process.
2. This is an example of a younger child.
3. A teen is planning for the future to set goals.
4. This is an example of a younger child.

KEY: Content Area: Cognitive Development | Integrated Processes: Nursing Process | Client Need: Psychological Integrity | Cognitive Level: Comprehension| REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. An age-appropriate activity for an adolescent would be all of the following except:
  2. Coloring.
  3. Creating music.
  4. A job.
  5. Reading.

 

ANS: 1

  Feedback
1. Coloring is appropriate for a younger child.
2. Creating music empowers teens to think abstractly.
3. A job creates responsibility and expectations from people outside of the immediate family.
4. Reading enables the teen to think abstractly and become inquisitive about the environment.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A teenage girl is trying on a skirt that her mother does not approve of wearing. The girl is exhibiting:
  2. Intimacy vs Isolation.
  3. Identity vs Role Confusion.
  4. Industry vs Inferiority.
  5. None of the above.

 

ANS: 2

  Feedback
1. The teen has not reached this stage in life yet.
2. The teen is attempting to “find herself,” thus attempting to test the parent’s boundaries.
3. A teen is beyond this stage.
4. The teen is exhibiting the process of identifying who she is and the boundaries her mother has set.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Parents of a 15-year-old girl are speaking about the difficulties their daughter has in following the household rules. Which response by the nurse would be the most appropriate?
  2. “Mood swings are more common in boys than girls, so this is normal.”
  3. “Your daughter is testing the limits. This is a part of normal development. Make sure that you are consistent with your rules, and she will learn to follow them.”
  4. “Girls tend to be more difficult than boys because they want to be the center of attention.”
  5. “She is attempting to get your attention because something is bothering her.”

 

ANS: 2

  Feedback
1. Mood swings can occur in both male and female teens.
2. The daughter is attempting to identify herself, and the boundaries that her parents set will demonstrate love for the child.
3. This behavior is not demonstrating a need to have all the attention.
4. Not following the rules does not indicate that something is bothering the child, other than having boundaries.

KEY: Content Area: Growth and Development | Integrated Processes: Teaching/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Analysis | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A nurse is evaluating a 17-year-old boy’s comprehensive cholesterol laboratory work. The result is 132 mg/dl. The nurse knows that:
  2. This is too high, and the boy should get a referral for a nutritionist.
  3. This is too high because of the types of foods teens prefer to eat.
  4. This is within normal limits, and the boy should continue with the same eating style.
  5. This is within normal limits because of the higher level of metabolism in teens.

 

ANS: 3

  Feedback
1. A nutritionist intervention is not needed.
2. The cholesterol level is within normal limits for a teenager.
3. The cholesterol level is within normal limits for a teenager.
4. An overall cholesterol level of 132 mg/dl is adequate at any age range.

KEY: Content Area: Nutrition | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Evaluation| REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A 15 year old has been an inpatient for the last 24 hours due to dehydration and vomiting. The nurse calculates the adolescents urine output for the shift at 0.3 ml/kg/hour. What does this result indicate?
  2. The result is low for this age range, and the patient needs more fluid intake.
  3. The result is normal, and the patient needs to maintain the level of fluid intake.
  4. The result is high, and an order for fluid restriction should be received.
  5. The result is higher than normal, but because of the diagnosis, the same fluid intake is adequate.

 

ANS: 1

  Feedback
1. The urine output is low, and the child needs more fluid intake.
2. The output is not normal. More fluids are needed.
3. The results are low, and the patient should not be fluid restricted.
4. The output is lower than normal, and the patient should have more fluid intake.

KEY: Content Area: Renal | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A 14-year-old girl is speaking to the school nurse about getting a belly button piercing. The nurse should educate the girl on:
  2. Getting permission from her parents.
  3. State laws for piercings.
  4. The influence this may have on peers.
  5. The nerve damage and infection that can occur with piercings.

 

ANS: 4

  Feedback
1. Permission from her parents can be a decision made by the girl. The nurse needs to provide information on what could occur with a piercing.
2. The piercing establishment is responsible for informing the client.
3. A teen is seeking acceptance from peers, and this would not be appropriate.
4. The side effects of the piercing and teaching on the signs and symptoms of infection should be provided by the nurse.

KEY: Content Area: Growth and Development | Integrated Processes: Teaching/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. During puberty, all of the following hormones are secreted at an increased rate except for:
  2. Estrogen.
  3. Androgens.
  4. Progesterone.
  5. ADH.

 

ANS: 4

  Feedback
1. Estrogen is produced at a higher rate in females.
2. Androgens are produced at a higher rate for sexual maturation.
3. Progesterone is produced at a higher level in females.
4. ADH is not influenced by the execrated growth period.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A growth spurt for boys usually occurs between which ages?
  2. 10 to 12 years of age
  3. 12 to 14 years of age
  4. 14 to 16 years of age
  5. 16 to 18 years of age

 

ANS: 2

  Feedback
1. Growth spurts for girls occur during this time.
2. The average age is between 12 to 14 years of age for a large growth spurt for boys.
3. Most boys have started their growth spurt before this time.
4. Most boys have started their growth spurt before this time.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. In the physical development of a boy, it is common to see:
  2. An increase in lean body mass and an increase in adipose body mass.
  3. An increase in adipose body mass and a decrease in lean body mass.
  4. An increase in lean body mass and a decrease in adipose body mass.
  5. A decrease in lean body mass and adipose body mass.

 

ANS: 3

  Feedback
1. Adipose body mass is not common in boys.
2. Lean body mass increases and the adipose tissue decreases during this time for boys.
3. Lean body mass increases and decreased adipose tissue are noted during this time for boys.
4. Lean body mass increases and adipose body mass decreases during this time for boys.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A 13-year-old boy presents with gynecomastia. The nurse knows this occurs because of:
  2. The increase in adipose tissue at this age.
  3. The increase in lean body mass.
  4. The increase in sex hormone production.
  5. The rapid metabolism at this age.

 

ANS: 3

  Feedback
1. Teenage boys have a decreased amount of adipose tissue.
2. Lean body mass does not influence the occurrence of gynecomastia.
3. Increased sexual hormone production in males can cause an increase in the breast tissue.
4. Gynecomastia is influenced by hormones, not metabolism.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A 13-year-old girl is crying in the nurse’s office at school because she has thick, white, odorless, discharge in her underwear. She is afraid she has some type of infection. The most appropriate question for the nurse to ask would be:
  2. “Have you started menstruating yet?”
  3. “When was the last time you had a shower?”
  4. “Have you had sexual intercourse?”
  5. “Do you take birth control pills?”

 

ANS: 1

  Feedback
1. The girl is exhibiting signs of leucorrhea, which can occur 3 to 6 months prior to menses.
2. The nurse has not assessed the hygiene of the patient.
3. Assessment of sexual history is important, but the nurse should prioritize the menses cycle because of her age.
4. Assessment of sexual history is important, but the nurse should prioritize the menses cycle because of her age.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Synthesis | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A 15-year-old, sexually active teenage girl comes to the outpatient clinic because she did not have her period this month. Upon assessment, the girl is not pregnant. The nurse says that irregular periods:
  2. Usually occur because of pregnancy.
  3. Can occur for 1 to 2 years after your first menses.
  4. Occur because of low stress situations.
  5. Are normal and should not be of concern.

 

ANS: 2

  Feedback
1. Periods do not occur if the patient is pregnant.
2. Irregular periods are common for the first two years after a girl starts her menstrual cycle.
3. Irregular periods can occur because of high stress situations, not low stress.
4. Irregular periods are not normal, and the patient should be evaluated if they continue after the first two years after she starts her menstrual cycle.

KEY: Content Area: Growth and Development | Integrated Processes: Teaching/Documentation | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A school nurse is leading a discussion about secondary sex characteristic development. Common characteristics for the adolescent age range are:
  2. Development of underarm and lower leg hair.
  3. Development of an Adam’s apple in girls.
  4. Enlargement of breast tissue in females.
  5. Increasing in height rapidly.

 

ANS: 1

  Feedback
1. Hair growth is a sign of secondary sexual characteristics.
2. Adam’s apples occur in boys.
3. Enlargement of breast tissue is known as a primary sexual characteristic.
4. Height is not a secondary sexual characteristic.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. During an assessment, the nurse notes Russell’s sign on a 15-year-old girl. The nurse should:
  2. Report this to the doctor because of possible eating disorder issues.
  3. Do nothing. This is a normal sign of development in girls.
  4. Document the lacerations and speak to the parents.
  5. Ask the teen if she is being abused.

 

ANS: 1

  Feedback
1. A positive Russell’s sign is a strong indication of an eating disorder.
2. The Russell’s sign gives indication of the need for medical and psychiatric intervention.
3. Documentation is needed, along with medical intervention.
4. The teen may not be forthright with information, and the doctor needs to be notified.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When administering medication to children and adolescents, it is important for the nurse to remember:
  2. Most medications have been tested on adults, not children, so there could be side effects that are not known with a medication.
  3. Medication should only be given in pill form for a child.
  4. Children should only take less than the prescribed amount of antibiotics for safety.
  5. Adolescents understand medication warnings best if written.

 

ANS: 1

  Feedback
1. The metabolism of children is different than adults, thus the nurse should watch for signs and symptoms of the side effects closer.
2. Medication may be given in a variety of forms for children to consume.
3. The fully prescribed amount of medication should be taken.
4. Adolescents understand the medication better if discussed.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Management | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. The acronym HEADSS for assessing adolescents stands for:
  2. Health, education, activities, sexuality, and safety.
  3. Home, education, activities, drugs, sexuality, suicide.
  4. Health, education, acne, diet, sexual preference, suicide.
  5. Home, education, activities, drugs, sexuality, safe sex.

ANS: 2

  Feedback
1. Home and drugs are included in the assessment.
2. All are part of the assessment.
3. Health, acne, and diet are not part of the assessment.
4. Safe sex is not part of the assessment.

KEY: Content Area: Safety | Integrated Processes: Communication | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge| REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When speaking with a teen about his/her home environment, the assessment should consist of:
  2. Review of the relationship with the parents and siblings.
  3. Assessing where the child sleeps.
  4. Assessing the types of food provided.
  5. Assessing school performance.

 

ANS: 1

  Feedback
1. Interactions between family members enable the nurse to assess the primary circle of support.
2. Sleeping arrangements do not give an indication as to the support of the teen.
3. Food is not a part of the primary support.
4. School performance is not part of the home environment assessment.

KEY: Content Area: Safety | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A higher incidence in concussions occurs during adolescence. The reason for this increase is:
  2. The lack of knowledge about brain trauma.
  3. Inadequate use of a helmet during contact sports.
  4. A feeling of being invincible.
  5. A teen does not care about health.

 

ANS: 2

  Feedback
1. There is significant research about brain trauma in adolescents.
2. Adolescent players do not take safety seriously, thus do not wear the safety devices correctly.
3. Teens feel invincible, but it is not the reason for higher incidence of concussions.
4. Teens generally have a sense of their personal health.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. The nurse has assessed a 16-year-old for cigarette smoking. The adolescent admits to smoking several times a day. A priority question to follow up with is:
  2. How often does the patient cough?
  3. How long has the patient been smoking?
  4. How does the patient obtain the cigarettes?
  5. How many other substances does the patient use?

 

ANS: 4

  Feedback
1. Assessment of coughing does not relate to the amount of cigarettes consumed.
2. The length of time for smoking for a teen is not lengthy enough to cause long-term damage.
3. Identifying the source for the cigarettes is not a priority at this point.
4. Cigarettes are a gateway substance that can lead to the use of other substances and should be assessed at this time.

KEY: Content Area: Growth and Development | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis| REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. The nurse is working on a study of obesity in adolescents. The nurse knows that if a child is obese in the adolescent years, than in the adult years, the patient has a _________ percent chance of obesity.
  2. 90
  3. 20
  4. 80
  5. 60

 

ANS: 3

  Feedback
1. The incidence is not this high.
2. 20 percent is too low of a rate.
3. 80 percent is the rate for a chance of obesity in adulthood.
4. The incidence is too low.

KEY: Content Area: Nutrition | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Obese adolescents are at an increased risk for developing all of the following except:
  2. Type 1 diabetes.
  3. Gastro esophageal reflux.
  4. Sleep apnea.
  5. Hyperlipidemia.

 

ANS: 1

  Feedback
1. Type 1 diabetes is not caused by obesity. Type 2 is caused by obesity.
2. Reflux is a common issue in individuals who are obese.
3. Sleep apnea occurs in obese individuals.
4. Hyperlipidemia can occur in obese adolescents because of fatty food choices.

KEY: Content Area: Nutrition | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When speaking to a group of 16-year-old boys about sexual intercourse, the nurse should include information about:
  2. Birth control options.
  3. Oral sex is a form of sex and should not be considered safer.
  4. Vaginal and oral sexual intercourse are safer than rectal sexual intercourse.
  5. HIV testing should only occur after the age of 20.

 

ANS: 2

  Feedback
1. A teenage boy should be concerned about birth control, but this is not the priority answer.
2. Explaining the difference and the risks for oral sex is the priority teaching.
3. One form of intercourse is not safer than the other.
4. HIV testing needs to be done if the teen is sexually active with multiple partners.

KEY: Content Area: Sexuality/Reproduction | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application| REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. The leading cause of death in adolescent males is:
  2. Suicide.
  3. Motor vehicle accidents.
  4. Falls.
  5. Homicide.

 

ANS: 4

  Feedback
1. The leading cause is not suicide.
2. The leading cause is not MVAs.
3. The leading cause is not falls.
4. The leading cause of death is homicide.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a 14-year-old boy who has been admitted for an exacerbation of sickle cell disease. The nurse is assessing the cognitive ability of the teen. The nurse must remember to include all of the following except:
  2. Assessing the developmental age, not the chronological age.
  3. Assessing the interactions between the patient and peers.
  4. Assessing how the child responds to the physical assessment.
  5. Assessing the physical maturation of the teen.

 

ANS: 4

  Feedback
1. Developmental age determines the cognitive ability of the teen. The chronological age does not take the cognitive ability into account.
2. Interactions will indicate the cognitive ability of the teen.
3. The physical assessment will give the nurse a chance to use questions and responses to assess the cognitive ability of the teen.
4. The physical maturation will not give an indication as to the cognitive ability of the teen.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Assessment | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A school nurse is giving information about the use of alcohol and partying activities for teen girls. The nurse should include which of the following in her teaching?
  2. Oral sexual encounters increase with the use of alcohol.
  3. A teen girl increases her chance for sexual assault when using alcohol.
  4. Boys have a higher sex drive when alcohol is being consumed.
  5. Alcohol causes teen girls to be outgoing.

 

ANS: 2

  Feedback
1. Oral sex can occur with or without the use of alcohol.
2. Alcohol can inhibit cognitive reasoning and can cause a woman to be seen as easy.
3. Sexual drive in boys versus girls is the same when using alcohol.
4. Alcohol can cause teenage girls to have increased mood swings and become weepy.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Common drugs used for date rape in teens include all of the following except:
  2. Hydroxybutyrate.
  3. Ketamine.
  4. Flunitrazepam.
  5. Diazepam.

 

ANS: 4

  Feedback
1. A common drug used in date rape.
2. A common drug used in date rape.
3. A common drug used in date rape.
4. Not seen often as a date rape drug.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge |  REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Cessation of menstrual periods after an established pattern of regularity could be an indication of:
  2. Too much meat in the diet.
  3. Deliberate food restriction.
  4. Venereal diseases.
  5. Late onset puberty.

 

ANS: 2

   
1. Could indicate a drop in body fat due to excessive exercising, deliberate food restriction/eating disorder, or illness
2. Could indicate a drop in body fat due to excessive exercising, deliberate food restriction/eating disorder, or illness
3. A venereal disease will not cause a difference in menstrual periods.
4. Late onset puberty will not cause a cessation of menstrual periods.

KEY: Content Area: Nutrition | Integrated Processes: Teaching/Learning | Client Need: Physiologic Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. During puberty, expected male anatomical changes include:
  2. Growth plates closing by age 16.
  3. Gynecomastia.
  4. Enlargement of the scrotum.
  5. Decrease in lean body mass.

 

ANS: 3

  Feedback
1. Growth plates close by age 20.
2. Gynecomastia refers to abnormal breast development in boys.
3. The scrotum and penis enlarge in boys during puberty.
4. During adolescence, lean body mass will increase in boys.

KEY: Content Area: Growth and Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Russell’s sign in an adolescent is a strong indication of:
  2. Scoliosis.
  3. Anorexia.
  4. Bulemia.
  5. STDs.

 

ANS: 3

  Feeback
1. Scoliosis affects the back and does not have the Russell’s sign.
2. Anorexia is an eating disorder characterized by food restriction.
3. Russell’s sign is abrasions or cuts on the knuckles from sticking fingers down throat to induce vomiting.
4. STDs are not related to the Russell’s sign.

KEY: Content Area: Nutrition | Integrated Processes: Teaching/Learning | Client Need: Physiologic Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. An accurate cultural assessment during a physical exam by the practitioner would include being knowledgeable about which of the following developmental characteristics of African American girls?
  2. Breast development starts earlier than in girls of other cultures.
  3. Native tongue language is always spoken among family members.
  4. African American girls reach puberty by age 10.
  5. Adipose tissue decreases at the onset of puberty.

 

ANS: 1

  Feedback
` Breast development starts in African American girls earlier than in girls of other cultures.
2. African American girls speak English.
3. Breast development may begin earlier, but full puberty does not occur at this age.
4. Adipose tissue may increase in some girls that are African American.

KEY: Content Area: Wellness/Cultural Diversity | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Parent education on Internet safety states that parents should be concerned if their teen:
  2. Gets unexplained phone calls late at night.
  3. Quickly changes the monitor screen when you enter the room.
  4. Receives gifts from an unknown person.
  5. All of the above.

 

ANS: 4

  Feedback
1. Signs that an adolescent is engaging in risky online behavior include initiating or receiving calls from individuals unknown to the caregiver.
2. Signs that an adolescent is engaging in risky online behavior are quickly changing the monitor screen when the caregiver approaches the computer.
3. Signs that an adolescent is engaging in risky online behavior include receiving mail/gifts from an unknown person.
4. Signs that an adolescent is engaging in risky online behavior include initiating or receiving calls from individuals unknown to the caregiver, receiving mail/gifts from an unknown person, and quickly changing the monitor screen when the caregiver approaches the computer.

KEY: Content Area: Wellness | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Synthesis | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A student nurse verbalizes understanding of medication administration in adolescents when she states:
  2. “Teens absorb medication at the same rate as adults.”
  3. “Most approved medications are safe for kids too.”
  4. “Medications are metabolized faster by a patient in puberty.”
  5. “Puberty has no effect on the elimination of medications.”

 

ANS: 3

   
1. After puberty, medication metabolism decreases to adult levels. Until that time, the teen will have a higher metabolism.
2. Over 75percent of medications are not approved for use in pediatric patients.
3. Most medications are metabolized faster by a patient in puberty.
4. Metabolizing medications is affected by puberty.

KEY: Content Area: Pharmacological | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A worrisome concern identified by the nurse during a social assessment of a teen at a routine appointment would be which response from the teen?
  2. Constantly wanting to be with friends
  3. Verbalizing that the mom is the teen’s best friend
  4. Wanting independence from family/caregivers
  5. Exploring different religious venues

 

ANS: 2

   
1. Social development includes socializing in cliques of the same sex and striving for peer acceptance.
2. Normal social development includes conflict between adolescents and caregivers.
3. Social development includes wanting independence from caregivers.
4. Adolescents may start to question/disagree with the religious beliefs of the family.

KEY: Content Area: Family Dynamics/Support Systems | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. You are preparing your 12-year-old patient for surgery tomorrow. Important concepts to remember regarding procedures include:
  2. Maintaining confidentiality.
  3. Educating the patient on the pain scale and comfort measures.
  4. Providing explanations and rationale to the patient and parents.
  5. All of the above.

 

ANS: 4

   
1. Nursing care procedures include maintaining patient confidentiality.
2. Nursing care procedures being honest about the potential for discomfort/pain.
3. Nursing care procedures include explaining rationales to the family and patient.
4. All of the above are appropriate nursing concerns regarding procedures.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When assessing home safety of the adolescent, it is essential to ask about all of the following except:
  2. Living arrangements.
  3. If they feel safe at home.
  4. Family income.
  5. Relationships with siblings.

 

ANS: 3

   
1. Assessment of the home includes asking where the adolescent lives.
2. Assessment of the home includes asking about violence in the home.
3. Assessment of the home does not include family income because all levels of income can have an unsafe living environment.
4. Assessment of the home includes asking about the relationships with siblings.

KEY: Content Area: Safety | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Leading causes of mortality in adolescents include:
  2. Homicide and suicide.
  3. Drowning.
  4. Cancer.
  5. Sports-related injuries.

 

ANS: 1

  Feedback
1. Leading causes of death in adolescence are motor vehicle accidents, homicide, and suicide.
2. Drowning is not the leading cause of mortality in this age range.
3. Cancer is not the leading cause of mortality in this age range.
4. Sports-related injuries rarely result in death.

KEY: Content Area: Accident/Injury Prevention | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. As a nurse, you are asked to educate your daughter’s sixth grade class on injury prevention. Which topic would not be appropriate to discuss in this setting?
  2. Seat belts
  3. Protective sports gear, such as helmets
  4. Safe sex
  5. Water safety

 

ANS: 3

  Feedback
1. Activities to provide information on regarding knowledge of safety prevention include wearing a seatbelt.
2. Activities to provide information on regarding knowledge of safety prevention include wearing protective gear, such as helmets, in order to prevent sports injuries.
3. Safe sex would not be appropriate to discuss. Activities to provide information on regarding knowledge of safety prevention include wearing a seatbelt, water safety, and wearing protective gear, such as helmets, to prevent sports injuries.
4. Activities to provide information on regarding knowledge of safety prevention include water safety.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. CRAFFT is the most reliable and valid screening tool used in adolescents to assess for:
  2. Alcohol and substance abuse.
  3. Mental health emergencies.
  4. High-risk behaviors.
  5. Eating disorders.

 

ANS: 1

  Feedback
1. CRAFFT was founded to be the most reliable and valid screening tool with adolescents for alcohol/substance use.
2. The assessment tool is not used for mental health emergencies.
3. The tool may identify abuse issues, but not risks.
4. Eating disorders are not identified using this scale.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. In establishing a nurse-patient relationship, the following boundaries should be observed except:
  2. Being nonjudgmental.
  3. Using humor appropriately.
  4. Developing trust.
  5. Being a friend.

 

ANS: 4

  Feedback
1. Establishing boundaries in a nurse-patient relationship includes being nonjudgmental.
2. Establishing boundaries in a nurse-patient relationship includes using humor appropriately.
3. Establishing boundaries in a nurse-patient relationship includes developing trust.
4. In establishing boundaries in a nurse-patient relationship, the nurse is not the adolescents’ friend, but a professional helper.

KEY: Content Area: Communication | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Assessing the Hospital Environment of Care for the adolescent should include:
  2. Personalizing their room.
  3. Decorating the walls with Toy Story prints.
  4. Allowing for privacy.
  5. Removing all chairs and extra furniture from the room.

 

ANS: 3

  Feedback
1. Environment of Care includes being aware that pediatric inpatient units are often geared toward younger children.
2. Posters with rock stars, popular actors, and famous athletes are preferred decorations over cartoon characters.
3. Allow for privacy by implementing curtains between bed spaces and locks on the bathroom door.
4. Comfortable furniture should be provided, with extra chairs for when family and peers visit.

KEY: Content Area: Therapeutic Environment | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Activities appropriate for the adolescent care unit might include all except:
  2. Access to snacks and beverages if there are no dietary restrictions.
  3. 5-year-old roommate.
  4. Private telephone conversations.
  5. Availability to games, such as pool tables.

 

ANS: 2

  Feedback
1. If not on a diet or activity restriction, offer kitchen access so that the adolescents can obtain beverages and snacks independently.
2. Adolescents prefer other adolescents as roommates. Avoid wide variation in ages during roommate selection.
3. Offer private telephone access.
4. Offer access to games that release physical energy, such as pool tables.

KEY: Content Area: Therapeutic Environment | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. The most effective method for teaching adolescents is:
  2. One-on-one verbal discussion.
  3. Written handouts.
  4. Web site access.
  5. Review content with parent only.

 

ANS: 1

  Feedback
1. Adolescents prefer one-to-one verbal dissemination of health education by a nurse rather than written materials, videos, or websites.
2. Written handouts are not effective and are often discarded.
3. Web sites may not offer the correct information, and the adolescent may not want to be seen on the Web sites.
4. Adolescent education includes providing education to both the patient and family.

KEY: Content Area: Wellness | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When educating parents on the care of their chronically ill child, the nurse should:
  2. Encourage the child’s dependence on the parents.
  3. Coordinate services between health-care providers, school, and home.
  4. Discourage the use of Internet resources.
  5. Address chronological age factors.

 

ANS: 2

  Feedback
1. Care for the chronically ill adolescent includes promoting self-care and functional independence.
2. Care for the chronically ill adolescent includes coordinating services between health-care providers, school, and home. Nurses should facilitate the transition from hospital to home.
3. Care for the chronically ill adolescent includes referring families and adolescents to appropriate Internet resources.
4. Psychosocial developmental care for the chronically ill adolescent includes using developmental, rather than chronological, age, as there may be some developmental delays.

KEY: Content Area: Wellness | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. A potential barrier to effective home care for a chronically ill child would be:
  2. Home care increases family satisfaction.
  3. Home care provides increased opportunities for socializing.
  4. Home care decreases financial costs, travel costs, and caregiver burden.
  5. Home care providers may feel anxious regarding administration of medications and treatments.

 

ANS: 4

  Feedback
1. Home care does increase family and adolescent satisfaction.
2. Adolescents may have increased opportunities for socializing with peers and participating in school/extracurricular activities as a result of having health-care needs met in the home.
3. Homecare does decrease financial costs, travel costs, and caregiver burden.
4. This is a potential barrier. Caregivers may feel anxious about having to administer treatments/medications.

KEY: Content Area: Illness Management | Integrated Processes: Nursing Process | Client Need: Physiologic Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Which of the following statements is true regarding the use of complimentary/alternative medicines (CAM) and adolescents?
  2. Adolescents openly discuss their use of CAM.
  3. CAM interactions with prescription and over-the-counter medications can lead to toxic effects.
  4. Half of adolescents have used CAM.
  5. Family and peer use of CAM has no influence on adolescent use.

 

ANS: 3

  Feedback
1. Adolescents are often reluctant to discuss their use of CAM.
2. Interactions with prescription and over-the-counter medications can lead to toxic or sub-therapeutic effects.
3. Nearly 80% of adolescents have used CAM therapies in their lifetime.
4. If an adolescent reports use by a close family member or peer, then he/she is more likely to also use CAM.

KEY: Content Area: Chemical Dependencies | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Items considered to be complimentary/alternative medicines (CAM) include all of the following except:
  2. Dietary and herbal supplements.
  3. Prescribed medications.
  4. Home remedies.
  5. Yoga.

 

ANS: 2

  Feedback
1. Dietary and herbal medications are considered CAM. They are not regulated by the FDA and have wide variations in content and dosage across manufacturers.
2. Prescribed medications are not CAM. These are regulated by the FDA.
3. Common home remedies used by adolescents, such as honey, lemon, and green tea, are considered CAM.
4. Yoga is a commonly used alternative therapy among adolescents.

KEY: Content Area: Chemical Dependency | Integrated Processes: Learning/Teaching | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When caring for an adolescent, all of the following are helpful safety strategies for avoiding sexual assault except:
  2. Staying in public areas.
  3. Avoiding alcohol.
  4. Traveling with a group of friends.
  5. Engaging in risky behaviors.

 

ANS: 4

  Feedback
1. Nurses should reinforce safety strategies for avoiding sexual assault, such as staying in public places.
2. Nurses should reinforce safety strategies for avoiding sexual assault, such as avoiding alcohol/substance use.
3. Nurses should reinforce safety strategies for avoiding sexual assault, such as going out with a group of friends.
4. Engaging in risky behaviors in not a safety strategy for avoiding sexual assault.

KEY: Content Area: Abuse | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. The American Academy of Pediatrics recommends yearly health maintenance visits with a primary care physician (PCP) for adolescents starting at age 11:
  2. until 15 years old.
  3. until 18 years old.
  4. until 21 years old.
  5. only when ill.

 

ANS: 3

  Feedback
1. The recommendation is up to 21 years of age.
2. The recommendation is up to the 21 years of age.
3. The American Academy of Pediatrics recommends yearly health maintenance visits with a primary care provider for adolescents between ages 11 and 21.
4. The American Academy of Pediatrics recommends yearly health maintenance visits with a primary care provider for adolescents between ages 11 and 21.

KEY: Content Area: Wellness | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. Leukorrhea, a thick, white vaginal discharge, is seen
  2. Prior to each menstrual cycle.
  3. 3 to 6 months before menarche.
  4. In sexually active teens.
  5. In early teen pregnancy.

 

ANS: 2

  Feedback
1. Leukorrhea, a thick, white discharge from the vagina, is seen 3 to 6 months before menarche.
2. Leukorrhea, a thick, white discharge from the vagina, is seen 3 to 6 months before menarche.
3. Leukorrhea can occur when an adolescent is sexually active, depending on if menarche has occurred.
4. Discharge during pregnancy should not occur.

KEY: Content Area: Growth and Developmental | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. When assessing a 15 year old, a practitioner would place her in which Erickson psychosocial development stage?
  2. Identity vs Role Confusion
  3. Intimacy vs Isolation
  4. Industry vs Inferiority
  5. Impulsivity vs Self-conflict

 

ANS: 1

  Feedback
1. Erickson’s psychosocial development stage for ages 12 to 18 is Identity vs Role Confusion.
2. Erickson’s psychosocial development stage for the age of 19 is Intimacy vs Isolation.
3. Erickson’s psychosocial development stage for ages 10 to 12 is Industry vs Inferiority.
4. Erickson’s psychosocial development for ages 12 to 18 is Identity vs Role Confusion.

KEY: Content Area: Growth and Developmental | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Multiple Choice

 

 

 

  1. TB screenings for at risk adolescents would not include those who:
  2. Have been incarcerated.
  3. Test positive for HIV.
  4. Are from non-U.S. countries.
  5. Live with their grandparents.

 

ANS: 4

  Feedback
1. Tuberculosis screenings for at risk adolescents include those who have been incarcerated.
2. Tuberculosis screenings for at risk adolescents include those who are HIV positive.
3. Tuberculosis screenings for at risk adolescents include those who are from countries outside of the United States.
4. Tuberculosis screening for at risk adolescents would not include those living with their grandparents.

KEY: Content Area: Wellness | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Choice

 

 

 

Matching

 

 

 

  1. When viewing physical development, an adolescent boy will reach Tanner’s stage 5 of sexual maturation in which order? (Number the following in the correct order)

__ Growth of axillary hair

__ Change in voice

__ Appearance of pubic hair

__ Downy hair on the upper lip

__ Increase in size of the testes and scrotum

__ Rapid growth of genitalia

ANS: 4, 6, 2, 5, 1, 3

KEY: Content Area: Sexual Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 10 | Type: Matching

 

 

 

Fill in the Blank

 

 

 

  1. A teen is being influenced by a peer to smoke marijuana. This teen is in the ___________________ vs ___________________ stage of psychosocial development.

ANS: Identity, Role Confusion

Feedback: The teen is attempting to identify with his/her peers and follow the role that parents have previously set.

KEY: Content Area: Growth and Development | Integrated Processes: Psychosocial | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 10 | Type: Fill in the Blank

 

 

 

Multiple Response

 

 

 

  1. The rapid growth of teens makes it important for them to receive increased amounts of which of the following minerals in their diet? Select all that apply.
  2. Iron
  3. Zinc
  4. Calcium
  5. Sodium
  6. Potassium

ANS: 1, 3

  Feedback
1. A higher metabolism needs the increased amount of iron.
2. Zinc needs are minimally affected by higher metabolism rates.
3. A higher metabolism needs the increased amount of calcium.
4. Sodium needs are minimally affected by higher metabolism rates.
5. Potassium needs are minimally affected by higher metabolism rates.

KEY: Content Area: Nutrition | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Response

 

 

 

  1. Common reactions of teen girls with premenstrual syndrome are: (Select all that apply.)
  2. Crying.
  3. Hallucinations.
  4. Breast tenderness.
  5. Weight gain.
  6. Feeling bloated.

ANS: 1, 3, 5,

  Feedback
1. Common in teens with premenstrual syndrome.
2. Not common in teens with premenstrual syndrome.
3. Common in teens with premenstrual syndrome.
4. Not common in teens with premenstrual syndrome.
5. Common in teens with premenstrual syndrome.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 10 | Type: Multiple Response

 

 

 

  1. The nurse is assessing the education of a 17-year-old girl. The nurse knows the influence of school can: (Select all that apply.)
  2. Create a sense of well-being and success if in a positive environment.
  3. Determine career choices.
  4. Determine the need for peer acceptance.
  5. Create anxiety for the girl and should be avoided.
  6. Cause self-doubt if not socially accepted by peers.

ANS: 1, 2, 3, 5

  Feedback
1. Positive environments increase the teen’s responses.
2. Specific courses aid in finding an area of interest for teens.
3. Peer acceptance is important at this age.
4. Avoiding situations because of anxiety does not lead to a positive influence.
5. Self-doubt can occur if the teen does not develop a group of friends.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 10 | Type: Multiple Response

 

 

 

True/False

 

 

 

  1. A 17 year old needs guardian consent for medical procedures.

ANS: T

  Feedback
1. A teen must be 18 years old to be classified as an adult for medical procedures, thus a guardian must consent for procedures.
2. A teen must be 18 years old to be classified as an adult for medical procedures, thus a guardian must consent for procedures.

KEY: Content Area: Legal | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 10 | Type: True/False

Chapter 22: Communicable Diseases

 

 

 

Multiple Choice

 

 

 

  1. Which of the following is a consideration in the administration of immunizations?
  2. Immunizations can only be administered if a child is free from any illnesses.
  3. Caregivers should administer aspirin prior to the injection to prevent any side effects.
  4. Children should be isolated from other children for 24 hours after receiving immunizations.
  5. Caregivers should be advised that immunizations may cause a mild fever or soreness and redness at the injection site.

 

ANS: 4

  Feedback
1. Children with mild signs and symptoms of a cold may receive immunizations. However, if they are febrile, it is better to hold off on the immunization until later.
2. Acetaminophen or ibuprofen are recommended to relieve any pain or fever following immunizations.
3. Generally, children do not need to be isolated from others after immunizations.
4. Some immunizations may cause a mild fever, or soreness and redness at the injection site. Caregivers may give acetaminophen or ibuprofen to relieve any pain or fever. Warm compresses may also be applied to the injection site.

KEY: Content Area: Reduction of Risk Potential | Integrated Processes: Caring | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A vaccine that contains fragments of cells that stimulate an immune response, but does not contain the whole cell is known as a:
  2. Toxoid.
  3. Subunit.
  4. Acellular.
  5. Attenuated.

 

ANS: 3

  Feedback
1. A toxoid vaccine is made from toxins produced by bacteria that are inactivated so that they cannot cause harm, but can still stimulate an immune response.
2. A subunit is produced from small fragments of viral protein.
3. An acellular vaccine contains fragments of cells that stimulate an immune response, but do not contain the whole cell.
4. An attenuated vaccine is one produced from the weakened virus.

KEY: Content Area: Immunization | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Which of the following is true about immunizations containing thimersal and autism?
  2. Thimersal has been removed from all vaccines.
  3. Only the MMR vaccine is associated with autism.
  4. Thimersal has been linked to learning disabilities, but not autism.
  5. Researchers have found no evidence that thimersal is linked to autism.

 

ANS: 4

  Feedback
1. Even though researchers have found no evidence that thimersal is linked to autism, the Advisory Committee on Immunization Practices has recommended that thimersal be removed from all vaccines.
2. Currently, this preservative is only found in very small amounts in some flu vaccines. Also, no evidence has been found that the MMR vaccine is associated with autism.
3. Even though researchers have found no evidence that thimersal is linked to autism, the Advisory Committee on Immunization Practices has recommended that thimersal be removed from all vaccines.
4. Even though researchers have found no evidence that thimersal is linked to autism, the Advisory Committee on Immunization Practices has recommended that thimersal be removed from all vaccines.

KEY: Content Area: Immunizations | Integrated Processes: Nurse Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 27-year-old mother has just delivered a healthy 7 lb. 3 oz. baby boy. Which of the following is true regarding the baby’s immunization schedule for Hepatitis B?
  2. The infant will need two doses administered at least 6 months apart.
  3. The infant should not receive the vaccine until at least 12 months of age.
  4. The infant will not need any vaccines at this time because of passive immunity from the mother.
  5. If the mother is Hepatitis B surface antigen positive, the baby will need 0.5ml of Hepatitis B Immune Globulin.

 

ANS: 4

  Feedback
1. Three doses of Hepatitis B are given before age 2: at birth, at 1 to 2 months of age, and after 24 weeks of age.
2. Three doses of hepatitis B are given before age 2: at birth, at 1 to 2 months of age, and after 24 weeks of age.
3. Immunity will not occur passively.
4. If the mother is Hepatitis B surface antigen (HbsAg) positive, 0.5 ml of Hepatitis B Immune Globulin (HBIG) is also given.

KEY: Content Area: Immunization | Integrated Processes: Nurse Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A mother is bringing her 2-month-old son in for his well-child visit. He is due to receive his Diphtheria, Tetanus, and Pertussis vaccine. The nurse is educating the mother on the possible side effects of the vaccine, which include:
  2. Pain and swelling in the joints.
  3. Irritability, loss of appetite, and seizures.
  4. Nausea, vomiting, and abdominal pain.
  5. Fever and decreased white blood cell count.

 

ANS: 2

  Feedback
1. Swelling occurs at the site, not the joints.
2. Side effects of the DTaP vaccine are irritability, loss of appetite, localized swelling, and seizures, which are rare.
3. Nausea and vomiting are rare.
4. Fever and a decreased white blood cell count are rare.

KEY: Content Area: Infectious Diseases | Integrated Processes: Teaching/ Learning | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. When a fetus receives antibodies from the mother by way of the placenta, this is known as:
  2. Active immunity.
  3. Natural Passive immunity.
  4. Transmission immunity.
  5. Attenuated immunity.

 

ANS: 2

  Feedback
1. Active immunity is when a person is exposed to the disease organism and makes his or her own antibodies.
2. Natural Passive immunity, a form of passive immunity, is when antibodies are passed from mother to fetus by way of the placenta
3. Transmission immunity does not exist.
4. Attenuated immunity occurs when a vaccine is given.

KEY: Content Area: Immunizations | Integrated Processes: Nurse Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Which of the following is a high risk group among children and adolescents for contracting Hepatitis B?
  2. Those living in institutions
  3. Individuals infected by sexual partners
  4. Children who are hemophiliacs or are receiving frequent blood transfusions
  5. All of the above

 

ANS: 4

  Feedback
1. High risk groups include those living in institutions.
2. High risk groups include those living in institutions, those involved in IV drug use, and those infected by sexual partners.
3. Hepatitis B is transmitted by blood or blood products, or by sexual contact. Children who are hemophiliacs or are receiving frequent blood transfusions are at risk. Individuals who have traveled to Africa or Asia are also at higher risk.
4. Hepatitis B is transmitted by blood or blood products, or by sexual contact. High risk groups include those living in institutions, those involved in IV drug use, those infected by sexual partners, and children who are hemophiliacs or are receiving frequent blood transfusions. Individuals who have traveled to Africa or Asia are also at higher risk

KEY: Content Area: Infectious Diseases | Integrated Processes: Nurse Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 15-year-old girl has been diagnosed with Hepatitis B and will be starting treatment with Interferon-alpha (IFN). The nurse needs to educate the patient on this medication. Which of the following should be included in this education?
  2. The medication reduces the replication of the Hepatitis B virus.
  3. The patient needs to remain on treatment for one year.
  4. Patients may develop resistance to Interferon-alpha over time.
  5. Interferon-alpha has fewer side effects than Lamivudine, which is also used to treat Hepatitis B.

 

ANS: 1

  Feedback
1. Interferon-alpha reduces the replication of the HBV virus. The medication is given as a subcutaneous injection three times a week for 4 to 6 months. Lamivudine, the other drug used to treat Hepatitis, has fewer side effects, but may patients develop a resistance.
2. The medication is given as a subcutaneous injection three times a week for 4 to 6 months.
3. Lamivudine, the other drug used to treat Hepatitis, has fewer side effects, but may patients develop a resistance.
4. Lamivudine, the other drug used to treat Hepatitis, has fewer side effects, but may patients develop a resistance.

KEY: Content Area: Infectious Diseases/Pharmacological | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 6-year-old boy with Varicella-zoster (chickenpox) and a visible rash is being admitted to the hospital for treatment of dehydration. Which of the following isolation precautions needs to be taken?
  2. Contact
  3. Airborne
  4. Contact and droplet
  5. Contact and airborne

 

ANS: 4

  Feedback
1. Transmission of the Varicella-zoster virus is from contact with fluid from vesicles of an infected person, secretions from the nose, mouth and eyes, and airborne from coughing and sneezing.
2. Transmission of the Varicella-zoster virus is from contact with fluid from vesicles of an infected person, secretions from the nose, mouth and eyes, and airborne from coughing and sneezing.
3. The transmission does not occur with droplets.
4. Transmission of the Varicella-zoster virus is from contact with fluid from vesicles of an infected person, secretions from the nose, mouth and eyes, and airborne from coughing and sneezing.

KEY: Content Area: Safety and Infection Control | Integrated Processes: Nurse Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The mother of a 4-year-old girl brings her daughter in to be evaluated for a fever of 101 degrees and a headache that has lasted for the past three days. The mother was concerned this morning when the child woke up and had reddened cheeks that looked like she had been slapped. The nurse suspects the child has:
  2. Impetigo.
  3. Fifth’s disease.
  4. German measles.
  5. Hand-Foot-Mouth Disease

 

ANS: 2

  Feedback
1. Crustations develop and serous drainage is present
2. The prodromal signs and symptoms of Fifth’s disease include fever, aching, and a headache. The child will also have erythema of the cheeks, giving the appearance of “slapped cheeks.”
3. Swelling of the glands and a rash occur
4. The hands and feet become very red, and a fever is usually present.

KEY: Content Area: Infectious Disease | Integrated Processes: Nurse Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

  1. Which of the following should be considered in the administration of the influenza vaccine?
  2. The vaccine is contraindicated for individuals who are allergic to eggs or egg products.
  3. The Live Attenuated Influenza Virus (LAIV) is a safe alternative for children of any age.
  4. The influenza vaccine is contraindicated in children with asthma and wheezing within the past

12 months.

  1. Since influenza has a bimodal seasonal pattern, children under 18 years of age should receive

two doses of the vaccine.

 

ANS: 1

  Feedback
1. The influenza vaccine is manufactured from the protein of eggs; therefore, the vaccine is contraindicated for those individuals who are allergic to eggs or egg products.
2. The live vaccine should not be given to children with asthma issues.
3. The nasal spray, live attenuated influenza virus is contraindicated for children with asthma and should not be given to children ages 2 to 4 who have been wheezing within the past 12 months.
4. Children through 8 years of age who are receiving their first influenza immunization need two doses, at least four weeks apart.

KEY: Content Area: Immunizations | Integrated Processes: Nurse Process| Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The period of time when a child begins to have mild signs and symptoms until the main illness appears, and which is associated with increased communicability, is referred to as:
  2. Transmission.
  3. Susceptibility.
  4. Prodromal period.
  5. Incubation period.

 

ANS: 3

  Feedback
1. Transmission is the mode of infecting others.
2. Susceptibility is the ability of a person to contract the illness.
3. Prodromal signs and symptoms may appear before a rash or the main illness appears and should be included in the physical assessment of a child with a communicable disease. The prodromal period is often associated with increased communicability of the disease. Prodromal signs and symptoms may include coryza, cough, fever, and malaise.
4. The incubation period is the time it takes for an individual to contract the disease to the start of the prodromal signs and symptoms.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nurse Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Reye’s Syndrome can be a life-threatening disease affecting the brain and liver of children. The cause of this disease comes from the ingestion of:
  2. Ibuprofen during a viral illness.
  3. Ibuprofen during a bacterial illness.
  4. Aspirin or other salicylates during a viral illness.
  5. Aspirin or other salicylates during a bacterial illness.

 

ANS: 3

  Feedback
1. Ibuprofen is safe for viral illnesses.
2. Ibuprofen is safe for bacterial illnesses.
3. Reye’s Syndrome typically follows a viral infection, such as chickenpox, influenza, or an upper respiratory infection. The ingestion of aspirin or other medication containing salicylates during a viral illness greatly increases the probability of developing the syndrome. Caregivers should be taught not to give aspirin or salicylate products to any child or adolescent during a febrile illness.
4. Reye’s Syndrome typically follows a viral infection, so it is acceptable to give aspirin or other salicylates for a bacterial infection.

KEY: Content Area: Infectious Diseases/Pharmacology | Integrated Processes: Nurse Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A mother brings in her 4-year-old daughter to be evaluated for a rash all over her torso. The mother states that the 4 year old was recently around her grandmother, who is presently recovering from shingles. The mother is now concerned that the child has contracted shingles. Which of the following would be an appropriate response by the nurse to the mother?
  2. “It is possible that she has contracted shingles from her grandmother.”
  3. “She has contracted chickenpox since both diseases are from the same virus.”
  4. “She can only get shingles from someone who has chickenpox.”
  5. “This rash does follow the normal pattern along a dermatome or particular nerve fiber.”

 

ANS: 1

  Feedback
1. However, a child may contract chickenpox from an individual with shingles.
2. Shingles is a reactivation of the Varicella-zoster virus that causes chickenpox. Caregivers should be educated that a child cannot get shingles from someone with chickenpox. However, a child may contract chickenpox from an individual with shingles. The chickenpox rash first appears on the trunk and face, whereas shingles follows dermatomes or particular nerve fibers.
3. Caregivers should be educated that a child cannot get shingles from someone with chickenpox. However, a child may contract chickenpox from an individual with shingles. The chickenpox rash first appears on the trunk and face, whereas shingles follows dermatomes or particular nerve fibers.
4. The chickenpox rash first appears on the trunk and face, whereas shingles follows dermatomes or particular nerve fibers.

KEY: Content Area: Infectious Diseases | Integrated Processes: Communication | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 6-year-old boy is admitted to the hospital with a severe case of chickenpox with persistent fever. The nurse monitors the child for which of the following complications?
  2. Pneumonia
  3. Kidney failure
  4. Seizure activity
  5. Rheumatic fever

 

ANS: 1

  Feedback
1. Complications from varicella-zoster or chickenpox include bacterial infections of the skin, pneumonia, septicemia, encephalitis, and bleeding problems.
2. Kidney issues are not usually present with chickenpox.
3. Seizures are rare with chickenpox.
4. Rheumatic fever is a complication of other bacteria.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nurse Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A nurse is working on a pediatric unit and notices that many of the children on the unit are admitted with a communicable disease. She realizes that the best action she can take to prevent the spread of communicable diseases is:
  2. Hand washing.
  3. Wearing gloves.
  4. Wearing gloves and a gown.
  5. Placing the child in isolation.

 

ANS: 1

  Feedback
1. The key to preventing the spread of communicable diseases is hand washing. Caregivers and children must be taught to wash hands before and after caring for infants and children, before eating and handling food, after using the bathroom or changing diapers, after handling animals, after playing in water or in the sand, and after using tissues to wipe eyes or noses.
2. Wearing gloves is only effective if hand washing occurs before and after use.
3. Gowning and gloving are the not primary barriers for preventing the spread of disease.
4. The child does not need isolation at this time.

KEY: Content Area: Safety and Infection Control | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. An 18-year-old boy is getting ready to leave for college and will be living in a dormitory. Which of the following vaccines is recommended prior to his departure?
  2. Hepatitis A
  3. Pneumococcal polysaccharide (PPSV23)
  4. Pneumococcal conjugate vaccine (PCV13)
  5. Meningococcal conjugate vaccine (MCV4)

 

ANS: 4

  Feedback
1. Hepatitis A is not recommended at this time.
2. The vaccine is not recommended at this time.
3. The vaccine is not recommended at this time.
4. College students are an at risk population for contracting meningitis since they live in close proximity to each other. The meningococcal conjugate vaccine (MCV4) is recommended for college students for the prevention of meningitis.

KEY: Content Area: Immunizations | Integrated Processes: | Nurse Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 16-year-old girl with mononucleosis is being evaluated for the development of a maculopapular rash. The nurse should ask the patient if she has taken which of the following medications?
  2. Acetaminophen
  3. Acyclovir
  4. Amoxicillin
  5. Aspirin

 

ANS: 3

  Feedback
1. Acetaminophen will not cause the side effects and is an acceptable medication.
2. Acyclovir is contraindicated.
3. A maculopapular rash will appear if amoxicillin or ampicillin is given to an individual with mononucleosis.
4. Aspirin should not be given to a child or an adolescent at any time.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nurse Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. An 8-year-old boy was just diagnosed with the mumps. The nurse is developing a plan of care for the boy, which should include which of the following interventions?
  2. Administer intravenous Acyclovir as ordered.
  3. Drink plenty of fluids, including citrus juices high in Vitamin C.
  4. Apply ice packs or warm compresses to the neck for comfort and pain relief.
  5. Place the patient in contact precautions.

 

ANS: 3

  Feedback
1. Acyclovir is not an effective treatment for mumps
2. Citrus juice should not be provided during this time.
3. Interventions for mumps include respiratory isolation; acetaminophen or ibuprofen for fever and pain; bland, soft foods; hydration with intravenous fluids or bland liquids, avoiding citrus juices; ice packs or warm compresses for the neck for comfort and pain relief; and snug-fitting underwear and warmth to provide comfort and pain relief for orchitis. Acyclovir is ineffective for the treatment of mumps.
4. Good hand washing is needed, not contact precautions.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nurse Process | Client Need Safe and Effective Care Environment Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Which of the following vaccines is contraindicated for those who are pregnant or immunocompromised?
  2. Tdap and Rotarix
  3. MMR and varicella
  4. Hepatitis and pneumococcal
  5. Pertussis and hemophilus influenza type b

 

ANS: 2

  Feedback
1. Tdap and Rotarix are not active viruses and can be given.
2. The MMR and varicella vaccines are manufactured from live attenuated or weakened viruses, and are contraindicated for those that are pregnant or immunosuppressed.
3. Hepatitis and pneumococcal are not live viruses.
4. Pertussis is not a live vaccine.

KEY: Content Area: Infectious Diseases| Integrated Processes: Nurse Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Small red spots in the mouth with a bluish-white center, also known as Koplik spots, are a characteristic sign of:
  2. Roseola
  3. Rotavirus
  4. Rubella
  5. Rubeola

 

ANS: 4

  Feedback
1. Roseola will cause a fine pin point rash on the trunk of the body.
2. Rotovirus will cause massive diarrhea stools.
3. Rubella cause the swelling of lymph nodes and a fine rash.
4. The prodromal signs and symptoms include coryza, cough, conjunctivitis, fever, malaise, and Koplik spots, small red spots in the mouth with a bluish-white center.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 6 month old is brought in to the office for a well-child visit. The baby was born prematurely at 34 week’s gestation. Which of the following vaccines is recommended for the infant to reduce the risk of Respiratory Syncytial Virus Bronchiolitis?
  2. Synagis
  3. RotaTeq
  4. Relenza
  5. Immune globulin

 

ANS: 1

  Feedback
1. Synagis has significantly reduced the incidence of RSV Bronchiolitis in infants. The immunization is recommended for infants who were born at less than 35 week’s gestational age or who have chronic lung or heart disease.
2. RotaTeq is used for the prevention of rotovirus, not RSV
3. Relenza is used for the treatment of influenza, not RSV.
4. The immune globulin is used in situations for patients that are not able to have the synagis vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Which of the following supplements has been recommended by the World Health Organization and has been found to reduce the risk of pneumonia and death from measles in children under age 2?
  2. Iron
  3. Folic Acid
  4. Vitamin A
  5. Vitamin D

 

ANS: 3

  Feedback
1. Iron deficiency does not influence the occurrence of pneumonia or measles.
2. Folic acid does not influence the occurrence of pneumonia or measles.
3. A systematic review and meta-analysis has found that Vitamin A therapy reduced the risk of pneumonia and death as a complication of measles for children under age 2 in areas of the world where Vitamin A deficiency was present.
4. Vitamin D does not influence the occurrence of pneumonia or measles.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nurse Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 6-week-old infant is brought into the emergency department with a cough that ends in a crowing sound, followed by vomiting. The nurse suspects which of the following illnesses?
  2. Pertussis
  3. Diptheria
  4. Bronchiolitis
  5. Respiratory Syncytial Virus

 

ANS: 1

  Feedback
1. Characteristic signs and symptoms of pertussis, or whooping cough, include cold symptoms with coryza, mild cough and fever in the early stages, progressing to a cough ending with a crowing (whooping) that may be severe enough to cause vomiting and cyanosis.
2. The child will have diarrhea and fevers with diphtheria.
3. The child will have symptoms of wheezing and difficulty breathing with Bronchiolitis.
4. The child will have large amounts of mucous and wheezing present with RSV.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 17-year-old boy is admitted with meningitis and for treatment of dehydration. The patient needs to be placed on droplet precautions. Which of the following interventions should be taken for droplet precautions?
  2. Anyone entering the room must wear gloves and a gown.
  3. The patient needs to be placed in a negative pressure room.
  4. Anyone entering the room needs to wear a respirator mask upon entering.
  5. The patient must wear a mask when being transported outside of the room.

 

ANS: 4

  Feedback
1. Gloves and a gown are required for contact precautions.
2. A negative pressure room is required for those on airborne precautions.
3. Respirator masks are required for some airborne illnesses.
4. Droplet precautions prevent the spread of diseases by close respiratory contact or respiratory secretions. Those in close contact with the patient must wear a mask. The patient must wear a mask when being transported outside of the room. A negative pressure room is required for those on airborne precautions. Respirator masks are required for some airborne illnesses. Gloves and gown are required for contact precautions.

KEY: Content Area: Safety and Infection Control | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 5-year-old girl is being admitted for dehydration from influenza. The girl is started on Tamiflu. Which of the following is true about the administration of this medication?
  2. Tamiflu is only effective for Influenza type A.
  3. Tamiflu is only effective for Influenza type B.
  4. The medication must be given within 48 hours of the onset of symptoms.
  5. The medication is not recommended for children with airway diseases, such as asthma.

 

ANS: 3

  Feedback
1. Two FDA approved antiviral medications have been recommended for influenza: Tamiflu and Relenza. These medications must be given within 48 hours of the onset of symptoms and are effective for both Influenza types A and B.
2. Two FDA approved antiviral medications have been recommended for influenza: Tamiflu and Relenza. These medications must be given within 48 hours of the onset of symptoms and are effective for both Influenza types A and B.
3. Two FDA approved antiviral medications have been recommended for influenza: Tamiflu and Relenza. These medications must be given within 48 hours of the onset of symptoms and are effective for both Influenza types A and B. Tamiflu may be given to children over 1 year of age, whereas Relenza is recommended for children over 7 years old. Relenza is administered as an inhalation medication and is not recommended for children with airway diseases, such as asthma.
4. Relenza is administered as an inhalation medication and is not recommended for children with airway diseases, such as asthma.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The agent responsible for the Hand-Foot-Mouth Disease is:
  2. Paramyxovirus.
  3. Coxsackie Virus.
  4. Human Herpesvirus 6.
  5. Human Parvovirus B 19.

 

ANS: 2

  Feedback
1. Paramyxovirus is the agent responsible for mumps.
2. The Coxsackie, or enterovirus, is the responsible agent for Hand-Foot-Mouth Disease.
3. The Human Herpesvirus 6 is responsible for Roseola.
4. The Human Parvovirus B 19 is the agent responsible for Fifth’s disease.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 16-year-old girl comes into the office for a sports physical. The recommendation is made for the girl to receive the Human Papillomavirus vaccine. Her mother is upset about the recommendation because she is sure her daughter is not yet sexually active. Which of the following responses would be most appropriate for the nurse to give?

 

  1. “Your daughter should receive the vaccine even though she has a yeast allergy.”
  2. “We need to give her a pregnancy test as well prior to administering the vaccine.”
  3. “She is overdue for the vaccine because she should have received it when she was 9.”
  4. “It is best if the vaccine is given before she becomes sexually active in order to prevent genital warts and cervical cancer in the future.”

 

ANS: 4

  Feedback
1. The vaccine should not be given if the child is allergic to yeast.
2. The nurse should educate the mother and daughter that the vaccine is best administered prior to becoming sexually active to prevent genital warts and cervical cancer from an HPV infection.
3. The HPV vaccine is generally given to girls ages 11 to 18, but can be given as early as age 9.
4. The HPV vaccine protects girls against HPV infections that may lead to genital warts and cervical cancer. It is generally given to girls ages 11to 18 prior to being sexually active, but can be given as early as age 9. The vaccine should not be administered if the girl is allergic to yeast. Health-care workers should check for pregnancy before giving the vaccine. Boys ages 9 to 18 may also receive the vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/ Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 2-month-old infant is presenting for a well-child visit and is due to receive the Rotavirus vaccine. The nurse recognizes that obtaining the patient’s history is essential in the administration of immunizations and preventing communicable disease. Which of the following should the nurse assess for prior to administering this vaccine?
  2. Lung disease
  3. Cardiac defects
  4. Seizure disorder
  5. Gastrointestinal disorders

 

ANS: 4

  Feedback
1. The immunization does not interfere with lung disease.
2. The immunization does not interfere with cardiac defects.
3. The immunization does not interfere with seizure disorders.
4. Rotavirus causes severe diarrhea and dehydration. The first immunization is given between 6 and 14 weeks. The immunization should be avoided if the child has a history of intussusception or other gastrointestinal disorders.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 3 year old is brought to the emergency department with a fever that has lasted for the past three days. The mother is concerned because the toddler is very lethargic. The child is crying, but the nurse notices no tears, and her eyes look sunken. The nurse anticipates which of the following priority interventions?
  2. Administering intravenous fluids
  3. Placing the child in contact precautions
  4. Decreasing stimulation and providing time to rest
  5. Administering antibiotics to reduce the child’s fever

 

ANS: 1

  Feedback
1. This child is demonstrating signs and symptoms of dehydration and needs immediate intervention with intravenous fluids. The nurse should also assess if the child has had a decreased urine output and continue to monitor the child’s intake and output.
2. The child is past the transmission state of illness.
3. These are important factors, but they are not the priority at this time.
4. Viral infections can cause fevers, and no antibiotics should be used at that time.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The Pneumococcal (PPSV23) vaccine is recommended for children with which of the following high-risk conditions?
  2. Asplenia
  3. Cochlear implants
  4. Congenital heart defects
  5. All of the above

 

ANS: 4

  Feedback
1. The Pneumococcal (PPSV23) vaccine is recommended for children and adolescents with high-risk conditions, such as asplenia. The vaccination should be repeated after five years.
2. The Pneumococcal (PPSV23) vaccine is recommended for children and adolescents with high-risk conditions, such as cochlear implants. The vaccination should be repeated after five years.
3. The Pneumococcal (PPSV23) vaccine is recommended for children and adolescents with high-risk conditions, such as congenital heart disease. The vaccination should be repeated after five years.
4. The Pneumococcal (PPSV23) vaccine is recommended for children and adolescents with high-risk conditions, such as cochlear implants, sickle cell anemia, congenital heart disease, or asplenia. The vaccination should be repeated after five years.

KEY: Content Area: Infectious Diseases | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The parents of a 1 year old have brought their child in to receive his vaccinations. The child is due for his fourth and final dose of Haemophilus Influenzae type B (HIB). The nurse reviews with the parents the importance of the vaccine in the prevention of:
  2. Pneumonia.
  3. Otitis media.
  4. Liver disease.
  5. Vomiting and diarrhea.

 

ANS: 2

  Feedback
1. The vaccine prevents conjunctivitis, otitis media, sinusitis, and has greatly reduced meningitis in young children.
2. Haemophilus Influenzae type B is a bacteria that causes infection in various parts of the body. The vaccine prevents conjunctivitis, otitis media, sinusitis, and has greatly reduced meningitis in young children.
3. The vaccine does not prevent against liver disease.
4. The vaccine will not stop vomiting or diarrhea.

KEY: Content Area: Infectious Diseases | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A family recently returned from a trip to Mexico. About one month after returning, the parents noticed that their 6-year-old child has dark urine and has been complaining of a stomachache and a poor appetite. Considering the history and clinical presentation of the child, the nurse suspects that the child may have which of the following?
  2. Malaria
  3. Hepatitis A
  4. Hepatitis B
  5. Clostridium Difficile

 

ANS: 2

  Feedback
1. A child with malaria would have constant diarrhea and fevers.
2. The clinical presentation in this scenario is that of Hepatitis A. The disease is often contracted when children travel outside of the country and ingest contaminated food or water. They may present with malaise, poor appetite, nausea, jaundice, abdominal pain, and dark urine. Children under the age of 6 may have mild or no symptoms. Children who are at risk for the disease or are traveling should receive the Hepatitis A vaccine.
3. The child would have signs of liver issues if the diagnosis was Hepatitis B.
4. The child is at low risk of contracting C. Diff in a foreign country.

KEY: Content Area: Infectious Diseases | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A mother and father are reading a pamphlet about the Hepatitis B series of vaccines for their newborn daughter. The father asks the nurse how many shots their baby will need to receive. The nurse knows that her teaching has been effective when the parents respond with:
  2. “A shot will be given today, then at her two month checkup, and again at her six month checkup.”
  3. “The shot cannot be given until she is at least 6 months old because she will need to build some immunity to the virus first.”
  4. “The injection is given in just one does, and then a booster is administered before she goes to school.”
  5. “She does not need the immunization because her mother was Hepatitis B negative.”

 

ANS: 1

  Feedback
1. This is the correct time frame for the vaccine administration for a newborn.
2. The vaccine can be given at birth, and the parents do not need to wait.
3. The vaccine requires a series of three injections.
4. Her mother’s status does not influence the need for the vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Synthesis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 9-year-old girl is scheduled to receive a series of the Hepatitis B vaccines because she did not receive them at birth. The child comes to the outpatient clinic for her second dose. Before offering the vaccine, the nurse assesses the child and asks the parents if she has an allergy to:
  2. Eggs.
  3. Penicillin.
  4. The previous dose of the Hepatitis B vaccine.
  5. Sulfonamides.

 

ANS: 3

  Feedback
1. This allergy does not affect the administration of the Hepatitis B vaccine.
2. This allergy does not affect the administration of the Hepatitis B vaccine.
3. If a reaction occurred with the first dose, there is a high probability the child is allergic to the vaccine, thus it should not be repeated.
4. This allergy does not affect the administration of the Hepatitis B vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The family is asking questions about the differences between Hepatitis A and Hepatitis B vaccines for their 2-year-old daughter. The nurse knows that the family understands the difference between the vaccines when the father states:
  2. “The Hepatitis A vaccine should be given at birth, then repeated six months later.”
  3. “The Hepatitis A vaccine is given in two doses, at least six months apart.”
  4. “The Hepatitis B vaccine requires a live virus, and the Hepatitis A vaccine does not.”
  5. “The Hepatitis B vaccine should not be given because our child is allergic to eggs.”

 

ANS: 2

  Feedback
1. The Hepatitis A vaccine should not be given until after the age of 12 months.
2. The Hepatitis A vaccine should be given in this manner.
3. Neither vaccine is live.
4. Hepatitis B vaccines can be given, even if the child is allergic to eggs.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Health Promotion/Maintenance | Cognitive Level: Analysis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A young mother calls the pediatric triage nurse because she is worried about her 4-month-old daughter. Her daughter had immunizations administered yesterday. The infant is not eating and is more irritable than usual. The nurse verifies that the infant had a DTaP immunization. The nurse knows that these signs and symptoms are:
  2. A medical emergency. The mother should bring the infant to an emergency room to make sure that the child is not having an allergic reaction.
  3. A normal reaction and will subside in a day or two.
  4. Abnormal, and the mother should follow up with the doctor in two days.
  5. Only occurring because the child has not been given Tylenol for the pain at the injection site.

 

ANS: 2

  Feedback
1. This is not a medical emergency. This is one of the side effects of the vaccine
2. This is a normal response to the vaccine.
3. This is normal and is one of the side effects of the vaccine.
4. The question does not assess what pain management has been done.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The pediatric nurse is discussing vaccines for a well-child check at 1 year of age. Common vaccines to give at this time include:
  2. Hib (Hemophilus Influenzae Type B)
  3. RotaTeq.
  4. MCV4 (Meningococcal).
  5. DRaP (Diphtheria, Tetanus, Pertussis).

 

ANS: 1

  Feedback
1. Recommended at this time
2. Not all children are required to have this vaccine.
3. Recommended later in life
4. Recommended earlier in life

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A nurse is reviewing the immunization schedule for a 9-month-old infant. The schedule notes that the child is due to receive the Rotarix vaccine today. During the assessment, the mother tells the nurse that the child had surgery three weeks ago for intussusception. The nurse knows that:
  2. The child should wait to get the vaccine because of the recent surgery.
  3. The child should not receive the vaccine because of the past history of intussusception.
  4. The child should be positioned so that the medication can be given orally.
  5. The child should receive the medication regardless of past history.

 

ANS: 2

  Feedback
1. The timing of the vaccine is not the priority.
2. A child with a GI issue should not receive Rotarix.
3. Does not come in oral form
4. Past history influences if the child can have the vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Lacey, a 9-year-old African American girl, has a history of Sickle Cell disease. She is scheduled to receive her polio vaccine today. The nurse knows that she should give the Inactive Poliovirus Vaccine (IPV) because:
  2. Lacey’s race has a higher risk of reaction to the oral vaccine.
  3. Lacey is too old for the oral vaccine.
  4. Lacey is at high risk for paralysis because of her immunodeficiency.
  5. The oral vaccine is not as effective for females as it is for males.

 

ANS: 3

  Feedback
1. Race does not cause the child to be at a higher risk for polio.
2. Age is not a disqualification for the vaccine.
3. Autoimmune deficiency can increase the occurrence of paralysis if the vaccine if given.
4. Gender does not determine the effectiveness of the vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Keegan, a 9-year-old patient, has been brought to the pediatric clinic for an influenza vaccine. The nurse knows that this is Keegan’s first time receiving the vaccine. The nurse knows the mother understands the instructions for the vaccine when she states:
  2. “I will not need to make sure he receives the vaccine every year.”
  3. “I cannot let him be around other children for at least 12 hours because he is contagious.”
  4. “I will need to watch him to see if he has an allergic reaction to eggs after this vaccine.”
  5. “I will need to bring him back in for a second immunization in four weeks.”

 

ANS: 4

  Feedback
1. A two-step flu vaccine is required when receiving the vaccine for the first time.
2. The vaccine does not spread the flu virus.
3. Reactions with eggs do not occur with this vaccine.
4. A two-step vaccination process is needed when receiving the flu vaccine for the first time.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A nurse has given instructions to the mother of a 5 year old child on common side effects after the measles, mumps, and rubella (MMR) vaccine. The common reactions include all but:
  2. Fever.
  3. Swollen cheeks.
  4. Pin point rash.
  5. Joint pain.

 

ANS: 3

  Feedback
1. Common side effect of the MMR vaccine
2. Common side effect of the MMR vaccine
3. An uncommon side effect and further assessment is needed
4. Common side effect of the MMR vaccine

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 1 year old has received her MMR and Varivax vaccines at the clinic today. The nurse explains the chance for rash and gives visual aids to the mother to take home. The nurse knows that the mother understands the normal reaction to Varivax when she points out:
  2. A varicella-type rash.
  3. A maculopapular rash.
  4. A pin point rash.
  5. A strawberry-patterned rash on her tongue.

 

ANS: 1

  Feedback
1. This is a normal reaction
2. An abnormal reaction with the Varivax vaccine
3. An abnormal reaction with the Varivax vaccine
4. An abnormal reaction with the Varivax vaccine

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A nurse is assessing a pediatric patient prior to giving the meningococcal vaccine. Which statement by the father would be an indication not to give the patient the vaccine?
  2. “She is allergic to those latex gloves you are using, so can you please use the latex-free ones?”
  3. “She is allergic to those latex-free gloves, so please use the latex gloves.”
  4. “She is allergic to gluten, so this vaccine should not be given.”
  5. “She is allergic to rubbing alcohol, so please do not cleanse the site with it.”

 

ANS: 1

  Feedback
1. The meningococcal vaccine should not be given to a child with a latex allergy.
2. Latex-free gloves do not cause hypersensitivity to the vaccine.
3. Gluten is not in the meningococcal vaccine.
4. Rubbing alcohol will not cause a major allergic reaction.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Iona has been brought to the clinic for her well-child checkup and immunizations. When the nurse completes the assessment, Iona is noted to have a low-grade fever. The nurse knows that:
  2. Iona should not receive the immunizations because her body is ill.
  3. Iona can receive the immunizations since the fever is low grade.
  4. Iona can receive the immunizations because the low-grade fever will increase the effectiveness of the vaccine.
  5. It is important to remain on schedule with the immunizations.

 

ANS: 1

 

  Feedback
1. A patient should be in good health prior to the administration of vaccines to help reduce the side effects.
2. A patient should be in good health prior to the administration of vaccines to help reduce the side effects.
3. A low-grade fever will increase the occurrence of the child obtaining the disease process.
4. It is important to remain on schedule with immunizations, but typical childhood illnesses last 10 to 14 days, and this will not change the schedule enough to make a difference.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The purpose of the vaccine information statement is:
  2. To give the purpose of the vaccine.
  3. To provide a list of possible side effects.
  4. To answer some questions for the caregiver.
  5. All of the above

 

ANS: 4

  Feedback
1. Correct, along with other answers
2. Correct, along with other answers
3. Correct, along with other answers
4. All of the statements should be included during teaching about immunizations.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Stella, a 16–year-old girl, has come to the clinic to receive the HPV vaccine. Prior to the administration of the vaccine, the nurse must assess for:
  2. Allergies to latex.
  3. Allergies to eggs.
  4. The last sexual encounter.
  5. Pregnancy.

 

ANS: 4

  Feedback
1. Latex is not a concern with this vaccination.
2. An allergy to eggs would not be a concern.
3. The last sexual encounter will not influence administration of the vaccine.
4. A woman who is pregnant should not receive the vaccine.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Identify the vaccine that is given to students prior to living in college dormitories.
  2. Influenza
  3. Meningococcal vaccine
  4. HPV
  5. MMR

 

ANS: 2

  Feedback
1. The influenza vaccine is required every year.
2. This disease is highly contagious in close living quarters and is required by many universities priority to living in the dormitories.
3. The HPV vaccine should be given prior to living in the dorms.
4. MMR is wanted, but not a requirement for many universities.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Assessment | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Micah has come for his pre-kindergarten checkup at the pediatric clinic. His mother reports that Micah is behind on his immunizations because of issues with extreme prematurity. She also reports that Micah had chicken pox three months ago. The nurse knows that Micah will have which type of immunity toward the Varicella-zoster virus?
  2. Vaccine-induced immunity
  3. Natural active immunity
  4. Passive active immunity
  5. None of the above

 

ANS: 2

  Feedback
1. The varicella-zoster vaccine was not given in order to produce immunity.
2. Since the child had the disease, the body is now immune to the disease.
3. The child did not receive immunity from his mother.
4. At least one of the above is correct.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Evaluation | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. In a nursing class, the instructor is discussing the differences between acellular vaccines and toxoids. The students are able to identify acellular vaccines because:
  2. The vaccines produce a toxin to get an immune response.
  3. The vaccine has a whole viral protein cell, unlike the toxoids.
  4. The vaccine has fragments of cells to stimulate an immune response.
  5. The vaccine is inactive and produced by whole cell bacteria.

 

ANS: 3

  Feedback
1. The toxin does not produce the immune response.
2. The cell proteins are not whole.
3. Fragments of the cell cause the immune response.
4. The vaccine is active and requires stimulation to create the immune response.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A nursing student is about to give a newborn baby a Hepatitis B injection. The student knows that the injection must be given IM. The best place to give an IM injection on a newborn is:
  2. The deltoid.
  3. The abdomen.
  4. The rectus femoris.
  5. The forearm.

 

ANS: 3

  Feedback
1. The deltoid lacks a large area of muscle in a newborn for IM injections.
2. IM injections should not be given in the abdomen.
3. The rectus femoris is easily identified and large enough for an IM injection for a newborn.
4. The forearm is not used for IM injections.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Which of the following vaccines can be given subcutaneously?
  2. MCV4
  3. Varicella
  4. MMR
  5. Rotavirus

 

ANS: 2

  Feedback
1. Given IM
2. Given IM
3. Given subcutaneously
4. Given via IV infusion or IM

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The pediatric nurse is teaching a young mother prodromal signs of communicable diseases at an in-home visit. The nurse knows that the mother understands the prodromal signs and symptoms when she states:
  2. “I will watch for coryza and vomiting to begin.”
  3. “I will need to watch for cough, coryza, and fevers.”
  4. “I will need to watch for a change in behavior and a low-grade fever.”
  5. “I will watch for a rash, fever, and vomiting.”

 

ANS: 2

  Feedback
1. Vomiting is not part of the prodromal signs.
2. Cough, coryza, and fevers are prodromal signs.
3. A low-grade fever is not a prodromal sign.
4. A rash and vomiting are not seen as prodromal signs.

KEY: Content Area: Immunizations | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Anne goes into her pediatric patient’s room for her 0400 assessment of a child who was admitted with dehydration 12 hours ago. Anne begins her assessment and knows that there is a medical emergency when the findings indicate:
  2. A child with a regular heart rate and a respiratory rate at the high end of normal.
  3. A child who is awake and wanting to play on the PS3.
  4. A child who has a purple rash in his extremities, and it does not blanch.
  5. A child who complains that he is tired and vomits thick mucus.

 

ANS: 3

  Feedback
1. A regular heart rate is not a medical emergency.
2. The child may not sleep well because of the environment.
3. The purple rash is a concern for the child’s circulatory system.
4. The thick mucus occurs because the child has been dehydrated.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Liza’s mother calls the pediatric triage nurse because she is concerned about her usually healthy daughter’s rosy, lacey cheeks, fever, and fussiness. The mother reports that this illness has been going around the day care. The nurse anticipates that the doctor’s orders will include:
  2. Acetaminophen, adequate hydration, and to let the virus run its course.
  3. Having the child admitted to the emergency room because this is a medical emergency.
  4. Having the mother speak with the day care and discuss good hand washing techniques.
  5. Giving the child TLC and hydration.

 

ANS: 1

  Feedback
1. The child is exhibiting a viral infection.
2. The signs and symptoms are not a medical emergency.
3. This would be appropriate to educate the mother, but this is not the primary answer for this question.
4. This would be appropriate, but it does not answer the question for the mother.

KEY: Content Area: Immunizations | Integrated Processes: Safe and Effective Care Environment | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A pregnant school teacher has been notified that there is a case of erythema infectiosum in her classroom. The school nurse speaks to the teacher because if she contracts erythema infectiosum, the mother and baby are at risk for:
  2. Growth restrictions in an unborn baby.
  3. The mother to have a miscarriage.
  4. The mother to have slow weight gain and affect the placenta.
  5. All of the above.

 

ANS: 2

  Feedback
1. Growth restriction is not a risk for the fetus.
2. The virus can cause a miscarriage in a pregnant woman.
3. Weight gain and the placenta are not affected by the virus.
4. One of the answers is correct.

KEY: Content Area: Immunizations | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Tabitha has been admitted with influenza. The nurse discusses the plan of care with the family. The child will be in droplet isolation. The reason for the droplet isolation is because:
  2. The goal is to not bring in any outside infections to the child, as pneumonia can be a complication.
  3. The goal is to prevent the spread of the virus to any of the health-care workers and other patients.
  4. The goal is to prevent a massive outbreak within the community.
  5. The goal is to provide a quiet environment for the child to rest.

 

ANS: 2

  Feedback
1. The child’s immune system is compromised, but the concern in droplet transfer to others.
2. Influenza is highly contagious through droplet formation. The isolation will help prevent the spread of the disease.
3. Influenza can be widespread, but the question is focusing on the family’s needs.
4. The child needs rest to recover, but the answer addresses the droplet communicability of Influenza.

KEY: Content Are: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. The doctor has prescribed Zanamivir for a 4-year-old patient. The nurse questions this order because:
  2. The medication is only to be given to adults with pneumonia.
  3. The medication is only recommended for infants with Hand-Foot-Mouth Disease.
  4. The medication is only recommended for ages 7 and older for Influenza.
  5. The medication has proven to be ineffective in the management of Influenza.

 

ANS: 3

  Feedback
1. The medication is recommended for adults to treat Influenza.
2. The medication should not be used in infants and is used for Influenza, not Hand-Foot-Mouth Disease.
3. The medication is for Influenza in children over the age of 7.
4. The medication is effective for a child over the age of 7 for Influenza.

KEY: Content Area: Pharmacological | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A 12-year-old girl presents to the emergency room with complaints of a sore throat, fever, and malaise for the past six days. The parents have noticed that she has been progressively sleeping more. The patient is diagnosed with mononucleosis. The caregiver education done by the nurse should include all of the following except:
  2. Rest periods should follow play/activity periods.
  3. After the girl goes back to school, she should not participate in ice hockey for 6 to 8 weeks.
  4. Keep her well hydrated, and provide nutrition that is high in protein.
  5. Give acetaminophen or ibuprofen for fever management.

 

ANS: 4

  Feedback
1. Rest periods should be provided for the child.
2. The child should not participate in contact sports for 6 to 8 weeks after having mononucleosis.
3. Hydration and a diet high in protein are needed for increasing the immune system.
4. Fever is not present at this stage of the healing process.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Logan, a, 11-year-old boy, was diagnosed with parotitis three days ago at the pediatric outpatient clinic. His mother calls the triage nurse to report that Logan is complaining of pain in his peritoneal area. The nurse knows that:
  2. This is a medical emergency, and Logan should be brought to the emergency room right away.
  3. The virus can cause orchitis.
  4. The virus can cause oophoritis.
  5. This is a common complaint because it is hard for a child with parotitis to urinate.

 

ANS: 2

  Feedback
1. Pain in the peritoneal area in common with this condition.
2. The virus is known to cause orchitis and has these signs and symptoms.
3. Oophoritis is not a sign or symptom of parotitis.
4. Urination is not an issue for a child with parotitis.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. RSV can be life threatening for infants and young children. Children who are at high risk for vulnerability to RSV include all of the following except:
  2. Immunocompromised school-age children.
  3. Infants with congenital heart defects.
  4. Premature infants.
  5. Respiratory compromised toddlers.

 

ANS: 1

  Feedback
1. RSV tends to affect younger children.
2. Children with a congenital heart defect are at a higher risk for susceptibility to RSV.
3. A premature infant is at a higher risk due to an immature immune system.
4. A toddler with respiratory issues has a compromised immune system, placing him/her at higher risk.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Jackson, a 9-month-old infant, is an inpatient on a pediatric floor due to a diagnosis of RSV. His mother is concerned because everyone comes into the room with a gown, mask, and gloves. The nurse attempts to educate his mother on the process of the disease. The nurse knows that the mother has an understanding of the illness when she states:
  2. “I can catch the virus just like a cold.”
  3. “The virus is spread by droplets, and the health-care workers need to make sure not to carry Jackson’s illness to other patients.”
  4. “This is to protect Jackson from getting an illness from the health-care providers.”
  5. “This is standard procedure on a pediatric floor during the RSV season.”

 

ANS: 2

  Feedback
1. Adults rarely have RSV.
2. RSV is spread by droplets, and the parent acknowledges that the disease can be spread through the health-care workers.
3. The child is contagious, not the health-care workers.
4. Standard procedures are not always known to the parents.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Evaluation | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Synagis is being prescribed for Kenyon, a 60-day-old, premature infant, prior to leaving the NICU. The nurse explains the reason for the medication to his mother. The mother understands that the medication will need:
  2. To be given in the pediatrician’s office every 28 to 30 days for the next year.
  3. To be given in the pediatrician’s office every 28 to 30 days for the next 3 to 5 months while it is RSV season.
  4. To be given in the pediatrician’s office at 6 months and again at 9 months.
  5. To be given in the pediatrician’s office at 1 year of age.

 

ANS: 2

  Feedback
1. The medication is not needed for an entire year.
2. The medication is given during the months when RSV is most prevalent.
3. The medication needs to be given monthly during the RSV season.
4. The medication needs to be given monthly during the RSV season.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Evaluation | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. An outbreak of German measles has occurred at the middle school. The school nurse has been notifying the parents of the children, along with the staff. The best prevention against contracting the highly contagious disease is:
  2. To keep ill children at home.
  3. To let children come to school after 16 days from the last known day of exposure because if there are no signs and symptoms, the child will not become ill.
  4. Receiving the MMR vaccine.
  5. Good hand washing.

 

ANS: 3

  Feedback
1. Keeping the ill child at home is preferred, but not the priority intervention.
2. Incorrect.  This is the incubation period for the German measles.
3. The best prevention is an immunization.
4. Hand washing is important for stopping the spread of the disease, but it is not the best option.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity| Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Photophobia can occur in which communicable disease process?
  2. German measles
  3. Influenza
  4. Rubeola
  5. Hand-Foot-Mouth Disease

 

ANS: 3

  Feedback
1. Photophobia is not present in German measles.
2. Photophobia is not usually present in Influenza.
3. Photophobia is common with Rubeola.
4. Hand-Foot-Mouth Disease does not have photophobia as a symptom.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. Jasmine’s mom calls the pediatric triage nurse and asks if she can give aspirin because of a fever and achiness due to chicken pox. The nurse knows that the mother understands the reason not to give the aspirin in this situation when she states:
  2. “If I give aspirin, she is as risk for major issues with her brain and liver.”
  3. “I can give the aspirin in a low dose and be safe.”
  4. “I can give the aspirin in three separate doses throughout the day.”
  5. “I should not give her aspirin because this can make her blood thin and not help with her get better.”

 

ANS: 1

  Feedback
1. Aspirin is not recommended for children due to the risk for liver and brain damage.
2. Any dose of aspirin for a child can cause damage to the liver and brain.
3. Any dosing schedule can cause damage to the child’s liver and brain.
4. The asprin may cause blood to thin, but the main concern is the development of Reye’s Syndrome.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

  1. A complication of scarlet fever is glomerulonephritis. This is because:
  2. The high doses of penicillin used to treat the disease process are hard for the kidneys to process.
  3. The group A beta-hemolytic streptococcus can affect the kidneys if not treated.
  4. The Epstein-Barr virus can affect the kidneys if not treated.
  5. The HIV irus can affect the kidneys if not treated.

 

ANS: 2

  Feedback
1. Penicillin does not affect kidney function.
2. Beta-hemolytic streptococcus can cause damage to the kidneys if not treated.
3. The Epstein-Barr virus is not present in scarlet fever.
4. The HAV virus is not present in scarlet fever.

KEY: Content Area: Communicable Diseases | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Choice

 

 

 

Multiple Response

 

 

 

  1. A 2-month-old presents to the pediatric clinic with a cough with crowing at the end, coryza, and vomiting. The diagnosis is whooping cough, and the child is taken immediately to the pediatric unit at the nearby hospital. The nurse explains the plan of care for the infant to the mother. The nurse should say: (Select all that apply.)
  2. “Feedings will be small in an attempt to keep the infant from vomiting.”
  3. “We will be watching how the infant breathes and will provide extra support if needed.”
  4. “We plan to wake the infant every hour in order to assess and feed the infant to make sure that he/she is getting enough calories.”
  5. “Cool mist humidification will be continuous to help keep the fever down.”
  6. “An IV will be placed for antibiotics.”

 

ANS: 1, 2, 5

  Feedback
1. Small, frequent feedings will decrease the chance for an emesis when the infant coughs.
2. Respiratory compromise occurs with whooping cough. It is important to provide support if needed.
3. Letting the infant rest is important to help with the healing process.
4. Cool mist humidification is used for keeping secretions thin, not for fever reduction.
5. IV antibiotics are an effective treatment for this disease process.

KEY: Content Area: Communicable Disease | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Response

 

 

 

  1. Malcolm has given his pediatric patient three vaccines. Documentation is being placed in the patient’s chart. Malcolm knows that he must document: (Select all that apply.)
  2. The lot number of the vaccine.
  3. The site of the injection.
  4. The date of administration.
  5. The consent for administration.
  6. The side effects the patient exhibited.

 

ANS: 1, 2, 3, 4

  Feedback
1. Needed for documentation
2. Needed for documentation
3. Needed for documentation
4. Needed for documentation
5. This is not required initially unless the patient exhibits a side effect.

KEY: Content Area: Immunizations | Integrated Processes: Communication/Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: CHAPTER 22 | Type: Multiple Response

 

 

 

  1. A day-care center calls the pediatric triage nurse because there has been an outbreak of Hand-Foot-Mouth Disease in the preschool room. It is important to teach the day-care center to: (Select all that apply.)
  2. Clean surfaces and toys with a mixture of disinfectant and bleach water.
  3. Practice good hand hygiene.
  4. Have the children stay home if they are active cases.
  5. Send information home with the parents.
  6. All of the above information should be given to the day-care center.

 

ANS: 5

  Feedback
1. Cleaning and disinfecting is needed.
2. Hand hygiene helps prevent the spread of illness.
3. An infected child should stay home.
4. The parents should receive education about the disease and the presence of it in the daycare.
5. All of the information should be provided and completed in the day-care center.

KEY: Content Area: Immunizations | Integrated Processes: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: CHAPTER 22 | Type: Multiple Response

 

 

 

Ordered Response

 

 

 

  1. Joshua is sent to the nurse’s office because the teacher thinks he has pink eye. The school nurse begins to assess his eye. She should: (Number the following in the correct order.)

___ Wash the eye from the inside corner to outside corner.

___ Provide a cool cloth to comfort the eye.

___ Wash hands and put on gloves.

___ Call his parents so they can take Joshua to the doctor for treatment.

____ Sanitize the nurse’s office, including door handles.

____ Sanitize Joshua’s classroom work area.

 

ANS: 2, 3, 1, 4, 5, 6

KEY: Content Area: Communicable Disease | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: Alternative Format

 

 

 

True/False

 

 

 

  1. Children may be given a calculated dose of acetaminophen or ibuprofen following an immunization.

 

ANS: T

  Feedback
1. The medication will aid in comfort for the child.
2. The medication will aid in comfort and should be given to the child.

KEY: Content Area: Pharmacological/Immunizations | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: CHAPTER 22 | Type: True/False