Chapter 37 Principles and Procedures for Nursing Care of Children

Chapter 37  Principles and Procedures for Nursing Care of Children

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. What is the most appropriate statement for the nurse to make to a 5-year-old child who is

undergoing a venipuncture?
a. “You must hold still or I’ll have someone hold you down. This is not going to

hurt.”
b. “This will hurt like a pinch. I’ll get someone to help hold your arm still so it will

be over fast and hurt less.”
c. “Be a big boy and hold still. This will be over in just a second.”
d. “I’m sending your mother out so she won’t be scared. You are big, so hold still and

this will be over soon.”

ANS: B
The nurse can help minimize the pain and stress of the venipuncture by having someone
help the child maintain control during the procedure. Threatening the child with having
someone hold him or her down is likely to produce less cooperation and frighten the
child. Telling a child to be a “big boy” does not acknowledge the child’s developmental
stage. Parents should be allowed to stay during procedures when possible.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 822 | Box 37.1 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity

2. Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of

immunosuppression?
a. Spiritual distress
b. Social isolation
c. Deficient diversional activity
d. Sleep deprivation

ANS: C
Children in isolation need extra attention to avoid boredom. A 5-year-old child is not
developmentally advanced enough to feel spiritual distress. The main social system for a
5-year-old child is the family, who should be allowed liberal visitation. Sleep deprivation
may occur during hospitalization but is not specific to isolation.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 825 OBJ: Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity

3. What should the nurse consider when having consent forms signed for surgery and

procedures on children?
a. Only a parent or legal guardian can give consent.
b. The person giving consent must be at least 18 years old.
c. The risks and benefits of a procedure are part of the consent process.
d. A mental age of 7 years or older is required for a consent to be considered

“informed.”

ANS: C
The informed consent must include the nature of the procedure, benefits and risks, and
alternatives to the procedure. In special circumstances, such as emancipated minors, the
consent can be given by someone younger than 18 years without the parent or legal
guardian. A mental age of 7 years is too young for consent to be informed.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 823 OBJ: Integrated Process: Communication and Documentation
MSC: Client Needs: Safe and Effective Care Environment

4. The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures.

Guidelines for preparing this preschooler should include
a. planning for a short teaching session of about 30 minutes.
b. telling the child that procedures are never a form of punishment.
c. keeping equipment out of the child’s view.
d. using correct scientific and medical terminology in explanations.

ANS: B
Illness and hospitalization may be viewed as punishment in preschoolers. Always state
directly that procedures are never a form of punishment. Teaching sessions for this
age-group should be much shorter in length. Demonstrate the use of equipment, and allow
the child to play with miniature or actual equipment. Explain the procedure in simple terms
and how it affects the child.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 821 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity

5. Which nursing action is most appropriate when treating a child who has a fever of 102.5° F

(39.1° C)?
a. Restrict fluid intake.
b. Administer an aspirin.
c. Administer acetaminophen.
d. Bathe the child in tepid water.

ANS: C
Treatment of a fever can include administration of an antipyretic such as acetaminophen.
Dehydration can occur from insensible water loss. Offer the child fluids frequently and
evaluate the need for IV therapy. Aspirin is avoided because of the potential association
with Reye syndrome. A sponge or tub bath with tepid water to reduce fever can cause
shivering and ultimately increase the child’s temperature.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 831 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity