Test Bank for Wongs Nursing Care of Infants and Children 9th Edition by Hockenberry

Test Bank

MULTIPLE CHOICE

1. Children are taught the values of their culture through observation and feedback, relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which of the following factors may be culturally determined?

ANS:  C

Status is culturally determined and varies according to each culture. Some cultures ascribe higher status to age or socioeconomic position. Social roles also are influenced by the culture. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. It is one component of culture. Race and culture are two distinct attributes. Racial grouping describes transmissible traits, whereas culture is determined by the pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. Cultural development may be limited by geographic boundaries, but the boundaries are not culturally determined.

DIF:    Cognitive Level: Analysis               REF:   p. 21

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Psychosocial Integrity

2. When minority groups immigrate to another country, a certain degree of cultural and ethnic blending occurs through the involuntary process of:

ANS:  A

Acculturation is the gradual changes that are produced in a culture by the influence of another culture that cause one or both cultures to become more similar. The minority culture is forced to learn the majority culture to survive. Ethnocentrism is the belief that one’s way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of one’s ethnic group are superior to those of others. Cultural shock is the helpless feeling and state of disorientation felt by an outsider attempting to adapt to a different culture group. Ethnocentrism and cultural shock would limit the amount of blending that would occur. Cultural sensitivity, a component of culturally competent care, is an awareness of cultural similarities and differences.

DIF:    Cognitive Level: Comprehension   REF:   p. 23

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

3. Which of the following terms best describes the emotional attitude that one’s own ethnic group is superior to others?

ANS:  D

Ethnocentrism is the belief that one’s way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of one’s ethnic group are superior to those of others. Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that serve as a frame of reference for individual perception and judgments. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. Superiority is the state or quality of being superior; it does not apply to ethnicity.

DIF:    Cognitive Level: Comprehension   REF:   p. 24

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

4. After the family, which of the following is likely to have the greatest influence on providing continuity between generations?

ANS:  B

The schools convey a tremendous amount of culture from the older members to the younger members of society. They prepare children to carry out the traditional social roles that will be expected of them as adults. Race is defined as a division of mankind possessing traits that are transmissible by descent and are sufficient to characterize it as a distinct human type; although race may have an influence on childrearing practices, its role is not as significant as that of schools. Social class refers to the family’s economic and educational levels. The social class of a family may change between generations. The government establishes parameters for children, including amount of schooling, but this is usually at a local level. The school culture has the significant influence on continuity.

DIF:    Cognitive Level: Knowledge          REF:   p. 25

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

5. The nurse observes that families from certain minority cultural groups often miss or are late for scheduled clinic appointments. The best explanation for this is that certain cultural groups often differ from the dominant culture because they:

ANS:  D

Each cultural group has different conceptions of time and waiting. The dominant culture in the United States has a fairly rigid view of time. Persons from other cultures may be late or miss activities because other issues take precedence over the appointment. Education is not the issue, nor is avoidance of health care. The family usually believes that the appointment can be made for a later time. The family does not forget the time, but other issues take priority.

DIF:    Cognitive Level: Application          REF:   p. 30

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

6. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. The best explanation for this, considering cultural differences, is that the parent:

ANS:  B

In some ethnic groups, eye contact is avoided. In the Vietnamese culture an individual may not look directly into the nurse’s eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse.

DIF:    Cognitive Level: Analysis               REF:   p. 32

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

7. The nurse is planning care for a patient with a different ethnic background. Which of the following would be an appropriate goal?

ANS:  A

Whenever possible, nurses should facilitate the integration of ethnic practices into health care provision. The ethnic background is part of the individual; it would be difficult to eliminate the influence of ethnic background. The ethnic practices need to be evaluated within the context of the health care setting to determine whether they are conflicting.

DIF:    Cognitive Level: Application          REF:   p. 36

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

8. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child’s mother says she has rubbed the edge of a coin on her child’s oiled skin. The nurse should recognize this is which of the following?

ANS:  B

This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the child’s oiled skin. The mother is attempting to rid the child’s body of disease. Coining is a cultural healing practice. Coining is not specific for enuresis or temper tantrums. This is not child abuse or discipline.

DIF:    Cognitive Level: Comprehension   REF:   p. 35

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

9. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which of the following would best explain this?

ANS:  C

In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and colddescribe certain properties completely unrelated to temperature. Respiratory conditions such as pneumonia are “cold” conditions and are treated with “hot” foods. The child may like broth but is unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe in chi as an innate energy.

DIF:    Cognitive Level: Application          REF:   p. 34

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

10. The nurse recognizes that some genetic diseases are more prevalent in certain groups and geographic areas. Which of the following disorders is more likely to be identified in individuals of Mediterranean descent?

ANS:  C

Glucose-6 phosphate dehydrogenase (G6PD) deficiency is more commonly found in individuals of Mediterranean descent. Phenylketonuria is more prevalent in individuals of northern European origin. Cystic fibrosis is more prevalent in individuals from England and Scotland. Sickle cell anemia is more prevalent in individuals of African descent.

DIF:    Cognitive Level: Application          REF:   p. 40

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

11. Which one of the following communicable diseases is more prevalent in certain ethnic groups, such as Vietnamese immigrants?

ANS:  A

Tuberculosis is a more prevalent communicable disease among certain ethnic groups such Vietnamese immigrants, Native Americans of the Southwest, and Mexican-Americans. Rubeola is a common communicable disease with a geographic constraint. Varicella and pertussis do not have ethnic prevalence.

DIF:    Cognitive Level: Application          REF:   p. 39

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1. The nurse is presenting a staff development program about cultural competency in the health care setting. Which of the following components should the nurse include in the program? Select all that apply.

ANS:  A, B, C, E

Five components that should be discussed in a program about cultural competency include awareness (the nurse appreciates and is sensitive to the family’s cultural values), knowledge (formal and informal education about different cultures, beliefs, and perceptions about health and wellness), skills (the ability to include cultural data in the nursing process), and desire (the genuine motivation to work effectively with minority patients). Cultural research and cultural bias are not components of cultural competency.

DIF:    Cognitive Level: Analysis               REF:   p. 36

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Psychosocial Integrity

Hockenberry: Wong’s Nursing Care of Infants and Children, 9th Edition

Chapter 14: Health Promotion of the Toddler and Family

Test Bank

MULTIPLE CHOICE

1. Which one of the following factors is most important in predisposing toddlers to frequent infections?

ANS:  D

Toddlers continue to have the short, straight internal ear canal of infants. The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections. The abdominal respirations and lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection. The defense mechanisms are more efficient compared with those of infancy.

DIF:    Cognitive Level: Analysis               REF:   p. 555

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

2. The psychosocial developmental tasks of toddlerhood include which of the following?

ANS:  D

If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to delay gratification. Development of a conscience and recognition of sex differences occur during the preschool years. The ability to get along with age-mates develops during the preschool and school-age years.

DIF:    Cognitive Level: Comprehension   REF:   p. 556

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

3. The developmental task with which the child of 15 to 30 months is likely to be struggling is a sense of what?

ANS:  D

Autonomy versus shame and doubt is the developmental task of toddlers. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of early childhood. Intimacy and solidarity versus isolation is the developmental stage of early adulthood.

DIF:    Cognitive Level: Knowledge          REF:   p. 583

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

4. A parent of an 18-month-old boy tells the nurse that he says “no” to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse’s best interpretation of this behavior is which of the following?

ANS:  A

Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and use of the word “no.” Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old.

DIF:    Cognitive Level: Comprehension   REF:   p. 556

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

5. A 17-month-old child would be expected to be in what stage, according to Piaget?

ANS:  C

The 17-month-old is in the fifth stage of the sensorimotor phase, tertiary circular reactions. The child uses active experimentation to achieve previously unattainable goals. Preoperations is the stage of cognitive development usually present in older toddlers and preschoolers. Concrete operations is the cognitive stage associated with the school-age child. Secondary circular reaction stage lasts from about ages 4 to 8 months.

DIF:    Cognitive Level: Comprehension   REF:   p. 556

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

6. Although a 14-month-old girl received a shock from an electrical outlet recently, her parent finds her about to place a paper clip in another outlet. Which of the following is the best interpretation of this behavior?

ANS:  C

During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. This is typical behavior for a toddler, who is only somewhat aware of a causal relation between events. Her cognitive development is appropriate for her age.

DIF:    Cognitive Level: Comprehension   REF:   p. 557

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

7. A toddler, age 16 months, falls down a few stairs. He gets up and “scolds” the stairs as if they caused him to fall. This is an example of which of the following?

ANS:  A

Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain the sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the inability to reverse or undo actions initiated physically. He is acting in an age-appropriate manner.

DIF:    Cognitive Level: Analysis               REF:   p. 559

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

8. Which of the following is a characteristic of a toddler’s language development at age 18 months?

ANS:  C

During the second year of life the comprehension and understanding of speech increase to a level far greater than the child’s vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. The 18-month-old has a vocabulary of approximately 10 words. At this age the child does not use the one-word sentences that are characteristic of 1-year-olds. The child has a very limited vocabulary of single words that are comprehensible.

DIF:    Cognitive Level: Comprehension   REF:   p. 561

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

9. Which of the following characteristics best describes the gross motor skills of a 24-month-old child?

ANS:  D

The 24-month-old child can go up and down stairs alone with two feet on each step. Skipping and broad jumping are skills acquired at age 3. Tricycle riding is achieved at age 4.

DIF:    Cognitive Level: Comprehension   REF:   p. 565

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

10. Which of the following developmental characteristics does not occur until a child reaches age 2 1/2 years?

ANS:  C

Usually by age 30 months the primary dentition of 20 teeth is complete. Birth weight doubles at approximately ages 5 to 6 months. The anterior fontanel closes at ages 12 to 18 months. Binocularity is established by age 15 months.

DIF:    Cognitive Level: Comprehension   REF:   p. 565

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

11. Which of the following statements is correct about toilet training?

ANS:  B

Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.

DIF:    Cognitive Level: Comprehension   REF:   p. 564

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

12. The parents of a newborn say that their toddler “hates the baby. . . . He suggested that we put him in the trash can so the trash truck could take him away.” The nurse’s best reply is which of the following?

ANS:  D

The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers have their entire schedule and routines disrupted because of the new family member. The nurse should work with parents on ways to involve the toddler in the newborn’s care and to help focus attention on the toddler. The toddler does not hate the infant. This is an expected, normal response to the changes in routines and attention that affect the toddler. The toddler can be provided with a doll to imitate parents’ behaviors. The child can care for the doll’s needs at the same time the parent is performing similar care for the newborn.

DIF:    Cognitive Level: Comprehension   REF:   p. 567

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Psychosocial Integrity

13. A toddler’s parent asks the nurse for suggestions on dealing with temper tantrums. Which of the following is the most appropriate recommendation?

ANS:  D

The best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common during this age-group as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The presence of the parent is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.

DIF:    Cognitive Level: Comprehension   REF:   p. 563

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

14. A parent asks the nurse about negativism in toddlers. The most appropriate recommendation is which of the following?

ANS:  D

The nurse should suggest to the parent that questions should be phrased with realistic choices rather than yes or no answers. This provides a sense of control for the toddler and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to comply with requests not to say “no.”

DIF:    Cognitive Level: Analysis               REF:   p. 568

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

15. The parents of a 2-year-old tell the nurse they are concerned because the toddler has started to use “baby talk” since the arrival of their new baby. The nurse should recommend which of the following?

ANS:  A

The baby talk is a sign of regression in the toddler. Often toddlers attempt to cope with a stressful situation by reverting to patterns of behavior that were successful in earlier stages of development. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children’s way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism.

DIF:    Cognitive Level: Application          REF:   p. 569

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

16. Parents tell the nurse that their toddler eats little at mealtime, only sits at the table with the family briefly, and wants snacks “all the time.” Which of the following should the nurse recommend?

ANS:  A

Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated with the slower growth rate. Parents should assist the child in developing healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should be not be used as positive or negative reinforcement for behavior. The child may develop habits of overeating or eat nonnutritious foods in response. A toddler is not able to understand explanations of what is expected of her and comply with the expectations.

DIF:    Cognitive Level: Application          REF:   p. 571

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

17. A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is which of the following?

ANS:  D

The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to maintain the sameness and reliability. It provides a sense of structure and comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. This does not indicate the child has unreasonable expectations, but rather is part of normal development. Ritualism is not regression, which is a retreat from a present pattern of functioning.

DIF:    Cognitive Level: Analysis               REF:   p. 556

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

18. The nurse is discussing with a parent group the importance of fluoride for healthy teeth. Which of the following should the nurse recommend?

ANS:  A

The decision about fluoride supplementation cannot be made until it is known whether the water supply contains fluoride and the amount. It is difficult to teach toddlers to spit out the mouthwash. Swallowing fluoridated mouthwashes can contribute to fluorosis. Fluoride supplementation is not recommended until after age 6 months and then only if the water is not fluoridated. Fluoridated toothpaste is still indicated if the fluoride content of the water supply is adequate, but very small amounts are used.

DIF:    Cognitive Level: Analysis               REF:   p. 573

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

19. Which of the following is an appropriate recommendation in preventing tooth decay in young children?

ANS:  B

Regular gum has high sugar content. When the child chews gum, the sugar is in prolonged contact with the teeth. Sugarless gum is less cariogenic than regular gum. Raisins, honey, and molasses are highly cariogenic and should be avoided. Sweets should be consumed with meals so that the teeth can be cleaned afterward. This decreases the amount of time that the sugar is in contact with the teeth.

DIF:    Cognitive Level: Analysis               REF:   p. 575

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

20. What is the leading cause of death during the toddler period?

ANS:  A

Injuries are the most common cause of death in children ages 1 through 4 years. It is the highest rate of death from injuries of any childhood age-group except adolescence. Congenital disorders are the second leading cause of death in this age-group. Infectious and childhood diseases are less common causes of death in this age-group.

DIF:    Cognitive Level: Comprehension   REF:   p. 575            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

21. The parent of 16-month-old Brian asks, “What is the best way to keep Brian from getting into our medicines at home?” The nurse should advise which of the following?

ANS:  A

The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize that all the different forms of medications in the home may be dangerous. Keeping medicines out of the homes of small children is not feasible. Many parents require medications for chronic or acute illnesses. Parents must be taught safe storage for their home and when they visit other homes.

DIF:    Cognitive Level: Application          REF:   p. 580

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

22. A toddler’s parents have been using a rear-facing convertible car seat since she was born. The seat can be safely switched to the forward-facing position when she weighs how many pounds?

ANS:  B

Although the transition point for switching to the forward-facing position is defined by the manufacturer, it is generally at 9 kg (20 lb); 4.5 kg (10 lb) is too small to be safe. Because of the relatively large head, this size child should be in the rear-facing position. It is usually safe to put children who weigh more than 20 lb in forward-facing convertible safety seats.

DIF:    Cognitive Level: Analysis               REF:   p. 576

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

23. The most common type of burn in the toddler age-group is:

ANS:  D

Scald burns are the most common type of thermal injury in children, especially 1- and 2-year-olds. Temperature should be reduced on the hot water in the house and hot liquids placed out of the child’s reach. Electric burns from electrical outlets and hot object burns from cigarettes or irons are both significant causes of burn injury. The child should be protected by reducing the temperature on the hot water heater in the home, keeping objects such as cigarettes and irons away from children, and placing protective guards over electrical outlets when not in use. Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age-group, but not one of the most common types of burn.

DIF:    Cognitive Level: Comprehension   REF:   p. 580            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

24. The nurse is assessing a 20-month-old toddler during a well-child visit and notices tooth decay. The nurse should understand that early childhood caries are caused by which of the following?

ANS:  D

One cause of early childhood caries is allowing the child to go to sleep with a bottle of milk or juice; as the sweet liquid pools in the mouth, the teeth are bathed for several hours in this cariogenic environment. Eating citrus fruit at bedtime and poor fluoride supply in drinking water do not cause early childhood caries. The problem is not hereditary and can be prevented with proper education.

DIF:    Cognitive Level: Comprehension   REF:   p. 575

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

25. The nurse is providing guidance strategies to a group of parents with toddlers at a community outreach program. Which of the following statements by a parent would indicate a correct understanding of the teaching?

ANS:  A

A 24-month-old toddler starts to show readiness for toilet training; it is important for the parent to be aware of this and be ready to start the process. At 18 months of age, a child needs consistent but gentle discipline, since the child cannot yet understand firmness and structure with discipline. Development of fears and need for security items usually occurs at the end of the 18- to 24-month stage. A 36-month-old child does not yet understand time and proximity of events, so the parent needs to understand that the toddler cannot “hurry up or we will be late.”

DIF:    Cognitive Level: Application          REF:   p. 582

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse is preparing a staff education program about growth and development of an 18-month-old toddler. Which of the following characteristics should the nurse include in the staff education program? Select all that apply.

ANS:  A, B, C, D

Tasks accomplished by an 18-month-old toddler include eating well with a spoon and cup, running clumsily, walking up stairs, pointing to common objects such as shoes, and building a tower with three or four blocks. An 18-month-old toddler has a vocabulary of only 10 words, not 300. Toddlers cannot dress themselves in simple clothing until 24 months of age.

DIF:    Cognitive Level: Application          REF:   pp. 562, 564

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

Hockenberry: Wong’s Nursing Care of Infants and Children, 9th Edition

Chapter 28: Balance and Imbalance of Body Fluids

Test Bank

MULTIPLE CHOICE

1. Which of the following is released from the posterior pituitary gland and promotes water retention in the renal system?

ANS:  D

ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone.

DIF:    Cognitive Level: Comprehension   REF:   p. 1055

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

2. Nurses must be alert for increased fluid requirements when a child has which of the following?

ANS:  A

Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children.

DIF:    Cognitive Level: Comprehension   REF:   p. 1055

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

3. Which of the following factors predisposes an infant to fluid imbalances?

ANS:  C

The infant’s kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.

DIF:    Cognitive Level: Comprehension   REF:   p. 1055

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

4. The number of milliliters of fluid per day needed for a 14 kg child is:

ANS:  C

For the first 10 kg of body weight a child requires 100 ml/kg. For each additional kilogram of body weight an extra 50 ml is needed.

10 kg ´ 100 ml/kg/day = 1000 ml

4 kg ´ 50 ml/kg/day = 200 ml

1000 ml + 200 ml = 1200 ml/day

Eight hundred to 1000 ml is too little; 1400 ml is too much.

DIF:    Cognitive Level: Application          REF:   p. 1055

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

5. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which of the following?

ANS:  C

These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.

DIF:    Cognitive Level: Comprehension   REF:   p. 1056

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

6. Clinical manifestations of sodium excess (hypernatremia) include which of the following?

ANS:  D

Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia.

DIF:    Cognitive Level: Comprehension   REF:   p. 1057

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

7. Which of the following laboratory findings would the nurse expect in a child with an excess of water?

ANS:  A

The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the child’s ability to correct the fluid imbalance.

DIF:    Cognitive Level: Comprehension   REF:   p. 1056

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

8. Which of the following is a clinical manifestation of calcium depletion (hypocalcemia)?

ANS:  D

Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia.

DIF:    Cognitive Level: Comprehension   REF:   p. 1058

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

9. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

ANS:  B

Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Hyperosmotic dehydration is another term for hypertonic dehydration.

DIF:    Cognitive Level: Comprehension   REF:   p. 1059

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

10. What amount of fluid loss occurs with moderate dehydration?

ANS:  B

Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss of 5% is considered mild dehydration. Less than 5% would be less severe. Weight loss over 15% is severe dehydration.

DIF:    Cognitive Level: Comprehension   REF:   p. 1061

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

11. Physiologically, the child compensates for fluid volume losses by which of the following mechanisms?

ANS:  C

Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure.

DIF:    Cognitive Level: Comprehension   REF:   p. 1059

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

12. Ongoing fluid losses can overwhelm the child’s ability to compensate, resulting in shock. Early clinical signs that precede shock include:

ANS:  A

Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse.

DIF:    Cognitive Level: Comprehension   REF:   p. 1060

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

13. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

ANS:  D

A good predictor of a fluid deficit of at least 5% is any two of the following four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed.

DIF:    Cognitive Level: Application          REF:   p. 1059

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

14. The nurse suspects fluid overload in an infant receiving intravenous fluids. Which of the following clinical manifestations is suggestive of water intoxication?

ANS:  C

Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the child attempts to maintain fluid balance. There is usually a weight gain associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication.

DIF:    Cognitive Level: Comprehension   REF:   p. 1062

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

15. Which of the following produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

ANS:  D

The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis.

DIF:    Cognitive Level: Comprehension   REF:   p. 1064

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

16. An approximate method of estimating output for a child who is not toilet trained is:

ANS:  B

Weighing diapers will provide an estimate of urinary output. Each 1 g weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the child’s skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating.

DIF:    Cognitive Level: Comprehension   REF:   p. 1068

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

17. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. Which of the following interventions will increase the visibility of these veins?

ANS:  A

Gently tapping the sight can sometimes cause the veins to be more visible. This is done before the skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst when punctured. Five minutes is too long.

DIF:    Cognitive Level: Application          REF:   p. 1074

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

18. When caring for a child with an intravenous infusion, the nurse should do which of the following?

ANS:  B

The nursing responsibility for intravenous therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma. A minidropper (60 drops/ml) is the recommended intravenous tubing in pediatric patients. Intravenous sites should be protected. This may require soft restraints on the child.

DIF:    Cognitive Level: Application          REF:   p. 1071

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

19. The nurse determines that a child’s intravenous infusion has infiltrated. The infused solution is a vesicant. The most appropriate nursing action is which of the following?

ANS:  B

A vesicant causes cellular damage when even minute amounts escape into the tissue. The intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is notified, and the treatment protocol is initiated. The application of heat or ice depends on the fluid that has extravasated. The catheter is left in place until it is no longer needed.

DIF:    Cognitive Level: Application          REF:   p. 1077

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

20. Several types of long-term central venous access devices are used. Which of the following is a benefit of using an implanted port (e.g., Port-a-Cath)?

ANS:  C

No limitations on physical activity are needed. The child is able to participate in all regular physical activities, including bathing, showering, and swimming. The skin over the device is pierced with a Huber needle to access. Long-term central venous access devices are difficult to use for self-administration. The port is placed under the skin. If the child manipulates the device and plays with the actual port, the catheter can be dislodged.

DIF:    Cognitive Level: Application          REF:   p. 1079          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

21. The nurse is teaching the family of a child with a long-term central venous access device. Symptoms of bacteremia, a serious complication, include which of the following?

ANS:  C

Fever, chills, general malaise, and an ill appearance can be signs of bacteremia and require immediate intervention. Hypotension would be indicative of sepsis and possible impending cardiovascular collapse. Pain, redness, and swelling at the entry site indicate local infection.

DIF:    Cognitive Level: Application          REF:   p. 1084

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

22. Which of the following flush solutions is recommended for intravenous catheters larger than 24 gauge?

ANS:  A

The recommended solution for flushing venous access devices is saline. The turbulent flow flush with saline is effective for catheters larger than 24 gauge. The use of heparin does not increase the longevity of the venous access device. In 24-gauge catheters, heparin may offer an advantage. Alteplase is used for treating catheter-related occlusions in children. The heparin-saline combination does not offer any advantage over saline or heparin individually.

DIF:    Cognitive Level: Application          REF:   p. 1078

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

23. The nurse is teaching a parent of a 10-year-old who will be discharged with a venous access device (VAD). Which of the following statements by the parent would indicate a correct understanding of the teaching?

ANS:  B

The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. The child should not participate in contact sports, even with a protective vest, to prevent the VAD from becoming dislodged. General malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for any length of time.

DIF:    Cognitive Level: Analysis               REF:   p. 1084

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

1. Which of the following conditions should the nurse be alert to for altered fluid requirements in children? Select all that apply.

ANS:  A, B, C

The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements.

DIF:    Cognitive Level: Application          REF:   p. 1053

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

2. Which of the following clinical manifestations would be observed in a 2-year-old with hypotonic dehydration? Select all that apply.

ANS:  B, C, D

Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration.

DIF:    Cognitive Level: Application          REF:   p. 1060

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

Hockenberry: Wong’s Nursing Care of Infants and Children, 9th Edition

Chapter 40: The Child with Neuromuscular or Muscular Dysfunction

Test Bank

MULTIPLE CHOICE

1. Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is which of the following?

ANS:  D

Approximately 80% of CP is caused by unknown prenatal causes. Neonatal encephalopathy in term and preterm infants is believed to play a significant role in the development of CP. CNS diseases such as meningitis or encephalitis can result in CP. Birth asphyxia does contribute to some cases of CP. Cerebral trauma, including shaken baby syndrome, can result in CP.

DIF:    Cognitive Level: Comprehension   REF:   p. 1692

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

2. Spastic cerebral palsy (CP) is characterized by which of the following?

ANS:  C

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic CP. Athetosis and dystonic movements are part of the classification of dyskinetic or athetoid CP. Tremors and lack of active movement may indicate other neurologic disorders. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic CP.

DIF:    Cognitive Level: Comprehension   REF:   p. 1693

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

3. Which of the following is the most common type of cerebral palsy (CP)?

ANS:  B

Spastic CP is the most common clinical type. Early manifestations are usually generalized hypotonia, or decreased tone that lasts for a few weeks or may extend for months or as long as a year. It is replaced by increased stretch reflexes, increased muscle tone, and weakness. Ataxic, dyskinetic, and mixed type are less common forms of CP.

DIF:    Cognitive Level: Comprehension   REF:   p. 1693

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

4. The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurse’s response should be based on which of the following?

ANS:  C

Children with CP have a wide range of intelligence, and 40% to 50% are within normal limits. A large percentage of children with CP do not have mental impairment. Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise.

DIF:    Cognitive Level: Comprehension   REF:   p. 1694

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

5. Gingivitis is a common problem in children with cerebral palsy (CP). Preventive measures include:

ANS:  B

Meticulous oral hygiene is essential. Many children with CP have congenital enamel defects, high-carbohydrate diets, poor nutritional intake, and difficulty closing their mouths. These, coupled with the child’s spasticity or clonic movements, make oral hygiene difficult. Children with CP have high carbohydrate intake and retention, which contribute to dental caries. Use of fluoride should be encouraged through fluoridated water or supplements and toothpaste. Certain medications such as phenytoin do contribute to gingival hyperplasia. If that is the drug of choice, then meticulous oral hygiene must be used.

DIF:    Cognitive Level: Analysis               REF:   p. 1701

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

6. The major goals of therapy for children with cerebral palsy (CP) include which of the following?

ANS:  D

The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious.

DIF:    Cognitive Level: Comprehension   REF:   p. 1695

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

7. The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes teaching on:

ANS:  B

Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy of Pediatrics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not effective for the muscle spasms of spastic CP.

DIF:    Cognitive Level: Application          REF:   p. 1703

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

8. A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. Which of the following is the most appropriate nursing action related to feeding Jason?

ANS:  B

Jaw control is compromised in many children with CP. More normal control is achieved if the feeder stabilizes the oral mechanisms from the front or side of the face. Bottle- or tube-feeding will not improve feeding without jaw support. The semireclining position and hyperextended neck position increase the chances of aspiration.

DIF:    Cognitive Level: Comprehension   REF:   p. 1698

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

9. An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurse’s response should be based on knowledge that:

ANS:  D

After-school and recreational activities serve to stimulate children’s interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are adapted for children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation.

DIF:    Cognitive Level: Application          REF:   p. 1699

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Psychosocial Integrity

10. A 4-month-old with significant head lag meets the criteria for floppy infant syndrome. A diagnosis of progressive infantile spinal muscular atrophy (Werdnig-Hoffmann) is made. Nursing care for this child includes:

ANS:  A

Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). An infant stimulation program is essential. Frequent position changes, including changes in environment, provide the child with more physical contacts. Verbal, tactile, and auditory stimulation is also included. Contractures do not occur due to the muscular atrophy. Sensation is normal in children with this disorder. Frequent touch is necessary as part of the stimulation. Werdnig-Hoffmann is inherited as an autosomal recessive trait. Parents should be referred for genetic counseling.

DIF:    Cognitive Level: Application          REF:   p. 1705          TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

11. An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, the nurse should consider which of the following?

ANS:  D

Recovery usually begins within 2 to 3 weeks, and most patients regain full muscle strength. The paralysis is progressive with proximal muscle weakness occurring before distal weakness. The recovery of muscle strength occurs in the reverse order of onset of paralysis. Most individuals regain full muscle strength. Better outcomes are associated with younger ages. GBS is an immune-mediated disease often associated with a number of viral or bacterial infections or the administration of vaccines.

DIF:    Cognitive Level: Comprehension   REF:   p. 1706

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

12. A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, the priority assessment includes:

ANS:  A

Assessment of swallowing is essential. Both pharyngeal involvement and respiratory function are usually involved at the same time. The child may require ventilatory support. The inability to swallow also contributes to aspiration pneumonia. Parental involvement is important after the physiologic assessment is complete. The child is answering questions and describing the onset of the illness, which demonstrates she is alert and oriented. Information regarding antecedent viral infections can be obtained after the child is assessed and stabilized.

DIF:    Cognitive Level: Application          REF:   p. 1706

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

13. Which of the following statements is most accurate in describing tetanus?

ANS:  C

Tetanus results from an infection by the anaerobic spore-forming, gram-positive bacillus Clostridium tetani. The organism forms two exotoxins that affect the central nervous system to produce the clinical manifestations of the disease. Tetanus is not an inflammatory process. The toxin acts at the neuromuscular junction to produce muscular stiffness and to lower the threshold for reflex excitability. It is usually a systemic disease. Initial symptoms are usually a progressive stiffness and tenderness of the muscles of the neck and jaw. The sustained contraction of the jaw-closing muscles provides the name lockjaw. Meningeal inflammation is not the cause of the muscle spasms.

DIF:    Cognitive Level: Comprehension   REF:   p. 1707

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

14. An adolescent whose leg was crushed when she fell off a horse is admitted to the emergency department. She has completed the tetanus immunization series, receiving the last tetanus toxoid booster 8 years ago. The therapeutic management of this adolescent to prevent tetanus should include which of the following?

ANS:  A

Protective levels of antibody are maintained for at least 10 years. Children with serious “tetanus-prone” wounds, including contaminated, crush, puncture, or burn wounds, should receive a tetanus toxoid booster prophylactically as soon as possible. This adolescent has circulating antibodies. The immunoglobulin is not indicated.

DIF:    Cognitive Level: Comprehension   REF:   p. 1707

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

15. During a well-child visit, the mother tells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the child’s diet. Which of the following might support this diagnosis?

ANS:  C

Ingestion of honey is a risk factor for infant botulism in the United States. Honey should not be given to children under the age of 1 year. Botulism is not found in commercial infant cereals. Although there is a slight increase in botulism in breast-fed infants when compared with formula-fed infants, there is not sufficient evidence to support formula-feeding as prevention. Thoroughly cleaning bottles used for formula feeding is sufficient for botulism prevention. Inadequate sterilization of home-canned foods can contribute to botulism.

DIF:    Cognitive Level: Comprehension   REF:   p. 1709

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

16. An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, “How bad is it?” The nurse’s response should be based on which of the following?

ANS:  C

The extent and severity of damage cannot be determined initially. The immediate loss of function is caused by anatomic and impaired physiologic function, and improvement may not be evident for weeks or months. It is essential to provide information about the adolescent’s status to the parents. Immediate treatment information should be provided. Long-term rehabilitation and prognosis can be addressed after the child is stabilized. During the immediate postinjury period, physiologic responses to the injury make an accurate assessment of damage difficult.

DIF:    Cognitive Level: Application          REF:   p. 1715

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Psychosocial Integrity

17. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Priority nursing interventions for this child includes which of the following?

ANS:  C

Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Increased blood pressure may be an indication of autonomic dysreflexia. It is not necessary to minimize environmental stimuli for this type of injury. Spinal cord injury is not an infectious process. Immunoglobulin is not indicated. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

DIF:    Cognitive Level: Application          REF:   p. 1717

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

18. Which of the following would the nurse expect in a child with a spinal cord lesion at C7?

ANS:  D

Individuals who sustain injuries at the C7 level are able to achieve a significant level of independence. Some assistance is needed with transfers and lower extremity dressing. Patients are able to roll over in bed and to sit and eat independently. Patients with injuries at C3 or higher have complete respiratory paralysis. Those with injuries at C4 or higher do not have voluntary function of higher extremities. Injuries at C5 or higher prevent this motor rolling over or sitting.

DIF:    Cognitive Level: Comprehension   REF:   p. 1713

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

19. An adolescent with a spinal cord injury is admitted to a rehabilitation center. Her parents describe her as being angry, hostile, and uncooperative. The nurse should recognize that this is suggestive of which of the following?

ANS:  C

During the rehabilitation phase it is desirable for adolescents to begin to express negative feelings toward the situation. The rehabilitation team can redirect the negative energy toward learning a new way of life. The injury has interrupted the normal adolescent process of achieving independence, triggering these negative behaviors. Severe depression can occur, but it indicates that the child is no longer in denial. Long-term therapy is not indicated. Being angry, hostile, and uncooperative are behaviors that are indications that the adolescent understands the severity of the injury and need for rehabilitation.

DIF:    Cognitive Level: Application          REF:   p. 1723

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Psychosocial Integrity

20. Which of the following statements best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)?

ANS:  C

DMD is characterized by a waddling gait and lordosis. Gower sign is a characteristic way of rising from a squatting or sitting position on the floor. DMD is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. Onset occurs usually between ages 3 and 5 years. DMD has a progressive and relentless loss of muscle function until death by respiratory or cardiac failure.

DIF:    Cognitive Level: Comprehension   REF:   p. 1726

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

21. The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). Which of the following statements should the nurse include in the training?

ANS:  B

CP has a variety of clinical classifications. Spastic pyramidal CP includes manifestations such as a positive Babinski sign and ankle clonus; ataxic CP has the wide-base gait and repetitive movements; hemiplegia CP is characterized by motor dysfunction on one side of the body with upper extremity more affected than lower limbs; and dyskinetic CP involves the pharyngeal and oral muscles, causing drooling and dysarthria.

DIF:    Cognitive Level: Application          REF:   p. 1693

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation

22. Which of the following findings would the nurse expect to observe in a 7-month-old infant with Werdnig-Hoffman disease? Select all that apply.

ANS:  C, D

Clinical manifestations of Werdnig-Hoffman disease in an infant include absent deep tendon reflexes, abnormal tongue movements, and failure to thrive. Scoliosis, prominent pectus excavatum, and significant leg involvement are findings observed in a child with intermediate spinal muscular atrophy.

DIF:    Cognitive Level: Comprehension   REF:   p. 1704

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Physiologic Adaptation