Download Wong's Nursing Care of Infants and Children 11th Edition Hockenberry Test Bank and more Exams Health sciences in PDF only on Docsity! Wong's Nursing Care of Infants and Children 11th Edition Wong's Nursing Care of Infants and Children 11th Edition Hockenberry Test Bank Chapter 1.Perspectives of Pediatric Nursing MULTIPLE CHOICE 1. The clinic nurse is reviewing statistics on infant mortality for the United States versus other countries. Compared with other countries that have a population of at least 25 million, the nurse makes which determination? a. The United States is ranked last among 27 countries. b. The United States is ranked similar to 20 other developed countries. c. The United States is ranked in the middle of 20 other developed countries. d. The United States is ranked highest among 27 other industrialized countries. ANS: A Although the death rate has decreased, the United States still ranks last in infant mortality among nations with a population of at least 25 million. The United States has the highest infant death rate of developed nations. DIF: Cognitive Level: Remembering REF: MCS: 6 TOP: Nursing Process: Assessment iMenStC: Cl Needs: Health Promotion and Maintenance 2.hWich is the leading cause of death in infants younger than 1 year in the United States? a. Congenital anomalies b. Sudden infant death syndrome c. Disorders related to short gestation and low birth weight d. Maternal complications specific to the perinatal period ANS: A Wong's Nursing Care of Infants and Children 11th Edition Congenital anomalies account for 20.1% of deaths in infants younger than 1 year compared with sudden infant death syndrome, which accounts for 8.2%; disorders related to short gestation and unspecified low birth weight, which account for 16.5%; and maternal complications such as infections specific to the perinatal period, which account for 6.1% of deaths in infants younger than 1 year of age. DIF: Cognitive Level: Remembering REF: MCS: 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. What is the major cause of death for children older than 1 year in the United States? a. Heart disease b. Childhood cancer c. Unintentional injuries d. Congenital anomalies ANS: C Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. The leading cause of death for those younger than 1 year is congenital anomalies, and childhood cancers and heart disease cause a significantly lower percentage of deaths in children older than 1 year of age. DIF: Cognitive Level: Understanding REF: MCS: 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 4. In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years? a. Suicide and cancer b. Suicide and homicide c. Drowning and cancer d. Homicide and heart disease Wong's Nursing Care of Infants and Children 11th Edition b. Family-centered care encourages family dependence on the health care system. c. Family-centered care recognizes that the family is the constant in a childs life. d. Family-centered care avoids expecting families to be part of the decision-making process. ANS: C The three key components of family-centered care are respect, collaboration, and support. Family-centered care recognizes the family as the constant in tchheilds life. T he family should be enabled and empowered to work with the health care system and is expected to be part of the decision-making process. The nurse should also support the familys cultural diversity, not reduce its effect. DIF: Cognitive Level: Applying REF: MCS: 8 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning? a. Purposeful and goal directed b. A simple developmental process c. Based on deliberate and irrational thought d. Assists individuals in guessing what is most appropriate ANS: A Clinical reasoning is a complex developmental process based on rational and deliberate thought. When thinking is clear, precise, accurate, relevant, consistent, and fair, a logical connection develops between the elements of thought and the problem at hand. DIF: Cognitive Level: Applying REF: MCS: 12 TOP: Integrated Process: Teaching/Learning Wong's Nursing Care of Infants and Children 11th Edition MSC: Client Needs: Health Promotion and Maintenance 10. Evidence-based practice (EBP), a decision-making model, is best described as which? a. Using information in textbooks to guide care b. Combining knowledge with clinical experience and intuition c. Using a professional code of ethics as a means for decision making d. Gathering all evidence that applies to the childs health and family situation ANS: B EBP helps focus on measurable outcomes; the use of demonstrated, effective interventions; and questioning what is the best approach. EBP involves decision making based on data, not all evidence on a particular situation, and involves the latest available data. Nurses can use textbooks to determine areas of concern and potential involvement. DIF: Cognitive Level: Remembering REF: MCS: 11 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 11. Which best describes signs and symptoms as part of a nursing diagnosis? a. Description of potential risk factors b. Identification of actual health problems c. Human response to state of illness or health d. Cues and clusters derived from patient assessment ANS: D Signs and symptoms are the cues and clusters of defining characteristics that are derived from a patient assessment and indicate actual health problems. The first part of the nursing diagnosis is the problem statement, also known as the human response to the state of illness or health. The identification of actual health problems may be part of the medical diagnosis. The nursing diagnosis is based on the human response to these problems. The human response is therefore a Wong's Nursing Care of Infants and Children 11th Edition component of the nursing diagnostic statement. Potential risk factors are used to identify nursing care needs to avoid the development of an actual health problem when a potential one exists. DIF: Cognitive Level: Understanding REF: MCS: 13 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment 12. The nurse is talking to a group of parents of school-age children at an after-school program about childhood health problems. Which statement should the nurse include in the teaching? a. Childhood obesity is the most common nutritional problem among children. b. Immunization rates are the same among children of different races and ethnicity. c. Dental caries is not a problem commonly seen in children since the introduction of fluoridated water. d. Mental health problems are typically not seen in school-age children but may be diagnosed in adolescents. ANS: A When teaching epnarts of sch ool-age children about childhood health problems, the nurse should include information about childhood obesity because it is the most common problem among children and is associated with type 2 diabetes. Teaching parents about ways to prevent obesity is important to include. Immunization rates differ depending on the childs race and ethnicity; dental caries continues to be a common chronic disease in childhood; and mental health problems are seen in children as young as school age, not just in adolescents. DIF: Cognitive Level: Applying REF: MCS: 3 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 13. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care? Wong's Nursing Care of Infants and Children 11th Edition d. Female, reacts negatively to new situations, no serious previous injuries ANS: B Boys have a preponderance for injuries over girls because of a difference in behavioral characteristics, a high taicvity t emperament sisocaisated w ith risk- taking behaviors, and stress predisposes children to increased risk taking and self-destructive behaviors. Therefore, a male child with a high activity level and living in a stressful environment has the highest number of risk factors. A girl with several siblings and a stable home life is low risk. A boy with vpiroeus injuries has two risk factors, but an even temper is not a risk factor for injuries. A girl who reacts negatively to new situations but has no previous serious illnesses has only one risk factor. DIF: Cognitive Level: Analyzing REF: MCS: 4 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 17. The school unautrisnegistheeval number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which? a. 50th percentile b. 75th percentile c. 80th percentile d. 95th percentile ANS: D Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender. DIF: Cognitive Level: Remembering REF: MCS: 3 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance Wong's Nursing Care of Infants and Children 11th Edition 18. The nurse is teaching parents about the types of behaviors children exhibit when living with chronic violence. Which statement made by the parents indicates further teaching is needed? a. We should watch for aggressive play. b. Our child may show lasting symptoms of stress. c. We know that our child will show caring behaviors. d. Our child may have difficulty concentrating in school. ANS: C The statement that the child will show caring behaviors needs further teaching. Children living with chronic violence may exhibit behaviors such as difficulty concentrating in school, memory impairment, aggressive play, uncaring behaviors, and lasting symptoms of stress. DIF: Cognitive Level: Applying REF: MCS: 6 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is evaluating research studies according to the GRADE criteria and has determined the quality of evidence on the subject is moderate. Which type of evidence does this determination indicate? a. Strong evidence from unbiased observational studies b. Evidence from randomized clinical trials showed inconsistent results c. Consistent evidence from well-performed randomized clinical trials d. Evidence for at least one critical outcome from randomized clinical trials had serious flaws ANS: B Evidence from randomized clinical trials with important limitations indicates that the evidence is of moderate quality. Strong evidence from unbiased observational studies and consistent evidence from well-performed randomized clinical trials indicates high quality. Evidence for at Wong's Nursing Care of Infants and Children 11th Edition least one ictrical outcome f rom randomizediclailntrials th at has serious wflas indi cates low quality. DIF: Cognitive Level: Remembering REF: MCS: 12 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 20. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions? a. Justice b. Autonomy c. Beneficence d. Nonmaleficence ANS: B Autonomy is the patients right to be self-governing. The adolescent is trying to be autonomous, so the nurse is supporting this value. tJhuestice is concept of fairness. Beneficence is the obligation to optreomthe pa tients well-being. Nonmaleficence is the obligation to minimize or prevent harm. DIF: Cognitive Level: Analyzing REF: MCS: 11 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 21. The nurse manager is compiling a report for a hospital committee on the quality of nursing- sensitive indicators for a nursing unit. Which does the nurse manager include in the report? a. The average age of the nurses on the unit b. The salary ranges for the nurses on the unit c. The education and certification of the nurses on the unit d. The number of nurses who have applied but were not hired for the unit Wong's Nursing Care of Infants and Children 11th Edition ANS: A, C, D, E The patients medical record shouldliundce: initial asse ssments, reassessments, ngursi care provided, and the patients response of care provided. Incident reports are not documented in the patients chart. DIF: Cognitive Level: Applying REF: MCS: 14 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment 4. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.) a. Buying clothes for the patients b. Showing favoritism toward a patient c. Focusing on technical aspects of care d. Spending off-duty time with patients and families e. Asking questions if families are not participating in care ANS: A, B, D Actions that show overinvolvement include buying clothes for patients, showing favoritism toward a patient, and spending off-duty time with patients and families. Focusing on technical aspects of care is an action that indicates underinvolvement, and asking questions if families are not participating in care indicates a positive action. DIF: Cognitive Level: Analyzing REF: pp. 9-10 TOP: Integrated Process: Caring MSC: Client Needs: Health Promotion and Maintenance 5. Which are included in the evaluation step of the nursing process? (Select all that apply.) a. Determination if the outcome has been met Wong's Nursing Care of Infants and Children 11th Edition b. Ascertaining if the plan requires modification c. Establish priorities and selecting expected patient goals d. Selecting alternative interventions if the outcome has not been met e. Determining if a risk or actual dysfunctional health problem exists ANS: A, B, D Evaluation is the last step in the nursing process. The nurse gathers, sorts, and analyzes data to determine whether (1) the established outcome has been met, (2) tnhuersing interventions were appropriate, (3) the plan requires modification, or (4) other alternatives should be considered. Establishing priorities and selecting expected patient goals are done in the outcomes identification stage. Determining if a risk or actual dysfunctional health problem exists is done in the diagnosis stage of the nursing process. DIF: Cognitive Level: Understanding REF: MCS: 14 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 6. Which should the nurse teach to parents regarding oral health of children? (Select all that apply.) a. Fluoridated water should be used. b. Early childhood caries is a preventable disease. c. Dental caries is a rare chronic disease of childhood. d. Dental hygiene should begin with the first tooth eruption. e. Childhood caries does not happen until after 2 years of age. ANS: A, B, D Oral health instructions to parents of children should include use of fluoridated water and dental hygiene beginning with the first tooth eruption. In addition, early childhood caries is a preventable disease and should be included in the teaching session. Dental caries is a common, not rare, chronic disease of childhood. Childhood caries may begin before the first birthday. Wong's Nursing Care of Infants and Children 11th Edition DIF: Cognitive Level: Applying REF: MCS: 2 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 7. The school nurse is explaining to older school children that obesity increases the risk for which disorders? (Select all that apply.) a. Asthma b. Hypertension c. Dyslipidemia d. Irritable bowel disease e. Altered glucose metabolism ANS: B, C, E Overweight youth have increased risk for a cluster of cardiovascular factors that include hypertension, altered glucose metabolism,iapniddedmyisal. I rritable bowel disease and asthm are not linked to obesity. DIF: Cognitive Level: Applying REF: MCS: 3 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading healthaitnodrisc? (Select all that apply.) a. Decrease tobacco use. b. Improve immunization rates. c. Reduce incidences of cancer. d. Increase access to health care. e. Decrease the number of eating disorders. Wong's Nursing Care of Infants and Children 11th Edition ANS: B Ethnocentrism is the belief that ones way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of ones ethnic group are superior to those of others. 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. Cultural shock is the helpless feeling and state of disorientation felt by an outsider attempting to adapt to a different culture group. Cultural sensitivity, a component of culturally competent care, is an awareness of cultural similarities and differences. DIF: Cognitive Level: Understanding REF: MCS: 35 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Itengrity 3. Which term best describes the sharing of common characteristics that fdeifrentiate s one group from other groups in a society? a. Race b. Culture c. Ethnicity d. Superiority ANS: C Ethnicity is a classification aimed at grouping individuals who consider themselves, or are considered by others, to share common characteristics that differentiate them ofrm t he other collectivities in a society, and from which they develop their distinctive cultural behavior. Race is a term that groups together people by their outward physical appearance. 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 ererfence for individual perception and judgments. Superiority is the state or quality of being superior; it does not apply to ethnicity. DIF: Cognitive Level: Understanding REF: MCS: 39 Wong's Nursing Care of Infants and Children 11th Edition TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. After the family, which has the greatest influence on providing continuity between generations? a. Race b. School c. Social class d. Government ANS: B Schools convey a tremendous amount of culture from the older members to the younger membersocoifetsy. They prepare children to carry oeutrt th aditional social roles that will be expected of them as adults.sRdaecfeinied as a division of humankind possessing traits that are transmissible by descent and are sufficient torcahcaterize race as a distinct hum an type; although race may have an influence on childrearing practices, its role is not as significant hasa t of schools. Social class refers to ethfamilys economic and educational levels. The social class of a family may change between generations. The government iesshtaebslparameters for children, including amount of schooling, but this is usually at a local level. The school culture has the most significant influence on continuity besides family. DIF: Cognitive Level: Remembering REF: MCS: 33 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Psychosocial Integrity 5. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal? a. Adapt, as necessary, ethnic practices to health needs. b. Attempt, in a nonjudgmental way, to change ethnic beliefs. c. Encourage continuation of ethnic practices in the hospital setting. d. Strive to keep ethnic background from influencing health needs. Wong's Nursing Care of Infants and Children 11th Edition 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 should 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: Applying REF: MCS: 34 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Itengrity 6. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The childs mother says she has rubbed the edge of a coin on her childs oiled skin. The nurse should recognize this as what? a. Child abuse b. Cultural practice to rid the body of disease c. Cultural practice to treat enuresis or temper tantrums d. Child discipline measure common in the Vietnamese culture ANS: B This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the childs oiled skin. The mother is attempting to rid the childs 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: Understanding REF: MCS: 41 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Psychosocial Integrity 7. 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 statement best explains this? Wong's Nursing Care of Infants and Children 11th Edition interaction. Interactional theory is not a mfaily thye. or Interactions are the basis of egreanl systems theory. Eriksons theory applies to individual growth and development, not families. Developmental systems theory is an outgrowth of Duvalls theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. DIF: Cognitive Level: Remembering REF: MCS: 19 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity 11. Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together? a. Blended b. Nuclear c. Extended d. Binuclear ANS: C An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. A blended family contains at least one stepparent, stepsibling, or half-sibling. A nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. DIF: Cognitive Level: Remembering REF: pp. 20-21 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. Which type of family should the nurse recognize when a mother, her children, and a stepfather live together? Wong's Nursing Care of Infants and Children 11th Edition a. Traditional nuclear b. Blended c. Extended d. Binuclear ANS: B A blended family contains at least one stepparent, stepsibling, or half-sibling. A traditional nuclearifsatsmoily cons f a married ceoaupl irnbdiothloegic children. No other relatives or nonrelatives are present in the household. An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. DIF: Cognitive Level: Remembering REF: MCS: 20 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Psychosocial Integrity 13. Which is an accurate description of homosexual (or egsabyi-aln) f amilies? a. A nurturing environment is lacking. b. The children become homosexual like their parents. c. The stability needed to raise healthy children is lacking. d. The quality of parenting is equivalent to that of nongay parents. ANS: D Although gay or lesbian families may be different from heterosexual families, the environment can be as healthy as any other. Lacking a nurturing environment and stability is reflective on the parents and family, not the type of family. There is little evidence to support that children become homosexual like their parents. DIF: Cognitive Level: Understanding REF: pp. 21-22 Wong's Nursing Care of Infants and Children 11th Edition TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 14. The nurse is teaching a group of new nursing graduates about identifiable qualities of strong families that help them function effectively. Which quality should be included in the teaching? a. Lack of congruence among family members b. Clear set of family values, rules, and beliefs c. Adoption of one coping strategy that always promotes positive functioning in dealing with life events d. Sense of commitment toward growth of individual family members as opposed to that of the family unit ANS: B A clear set of family rules, values, and beliefs that establish expectations about abccleepatnd desired behavior is one of the qualities of strong families that help them function effectively. Strong families have a sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs. Varied coping strategies are used by strong families. The sense of commitment oiswtard t he growth andlwel -being of individual family members, as well as the family unit. DIF: Cognitive Level: Applying REF: MCS: 22 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 15. When assessing a mfaily, the enudres termines that the rpa ents exert little or no control over their children. This sletyof parenting is called which? a. Permissive b. Dictatorial c. Democratic d. Authoritarian Wong's Nursing Care of Infants and Children 11th Edition The area must be nonstimulating and safe. The child becomes bored in this environment and then changes behavior to rejoin activities. The childs room may have toys and activities that negate the effect of being separated from the family. The general rule is 1 minute per year of age. An hour per year is excessive. When the child cries, refuses, or is more disruptive, the time-out does not start; the time-out begins when the child quiets. DIF: Cognitive Level: Remembering REF: MCS: 26 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 19. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response? a. It is best to wait until the child asks about it. b. The best time to tell the child is between the ages of 7 and 10 years. c. It is not necessary to tell a child who was adopted so young. d. Telling the child is an important aspect of their parental responsibilities. ANS: D It is important for the parents not to withhold information about the adoption from the child. It is an essential component of the childs identity. There is no recommended best time to tell children. It is believed that children should be told young enough so they do not remember a time when they did not know. It should be done before the children enter school to prevent third parties from telling the children before the parents have had the opportunity. DIF: Cognitive Level: Analyzing REF: MCS: 27 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity Wong's Nursing Care of Infants and Children 11th Edition 20. Children may believe that they are responsible for their parents divorce and interpret the separation as punishment. At which age is this most likely to occur? a. 1 year b. 4 years c. 8 years d. 13 years ANS: B Preschool-age children are most likely to blame themselves for tdhievorce. A 4 -year-old child will fear abandonment and express bewilderment regarding all human relationships. A 4-year-old child has magical thinking and believes his or her actions cause consequences, such as divorce. For infants, divorce may increase their irritability and interfere with the attachment process, but they are too young to feel responsibility. School-age children will have feelings of deprivation, including the loss of a parent, attention, money, and a secure future. Adolescents are able to disengage themselves from the parental conflict. DIF: Cognitive Level: Analyzing REF: MCS: 29 TOP: Nursing Process: Planning MSC: Client cNheoesdosc:iPalsyI ntegrity 21. A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what? a. Indicative of maladjustment b. A common reaction to divorce c. Suggestive of a lack of adequate parenting d. An unusual response that indicates a need for referral ANS: B Wong's Nursing Care of Infants and Children 11th Edition Parental divorce affects school-age children in many ways. In addition to difficulties in school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of appetite, and sleep disorders. The childs responses are common reactions of school-age children to parental divorce. DIF: Cognitive Level: Applying REF: MCS: 29 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 22. A mother brings 6-month-old Eric to the caliwnic for ell-baby checkup. She comments, I want to go back to work, but I dont want Eric to suffer because Ill have less time with him. Which is the nurses most appropriate answer? a. Im sure hell be fine if you get a good babysitter. b. You will need to stay home until Eric starts school. c. Lets talk about the child care options that will be best for Eric. d. You should go back to work so Eric will get used to being with others. ANS: C Asking the mother about child care options is an open-ended statement that will assist the mother in exploring her concerns about what is best for both her and Eric. The other three answers are directive; they do not address the effect that her working will have on Eric. DIF: Cognitive Level: Applying REF: MCS: 32 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 23. A fteorsparent is talking to the nurse about the health care needs for tchheild w ho has been placed in the parents care. eWmheincht children? stat best describes the health care needs of tfeors Wong's Nursing Care of Infants and Children 11th Edition c. Siblings d. Teachers ANS: A Adolescents from a large family are more peer oriented than family oriented. Adolescents in small families identify more strongly with their parents and rely more on them for advice. DIF: Cognitive Level: Understanding REF: MCS: 23 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Itengrity 27. The nurse is explaining different parenting styles to a group of parents. The nurse explains that an authoritative parenting style can lead to which child behavior? a. Shyness b. Self-reliance c. Submissiveness d. Self-consciousness ANS: B Children raised by parents with an authoritative parenting style tend to have high self-esteem and are self-reliant, assertive, inquisitive, content, and highly interactive with other children. Children raised by parents with an authoritarian parenting style tend to be sensitive, shy, self- conscious, retiring, and submissive. DIF: Cognitive Level: Applying REF: MCS: 24 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 28. Parents of a preschool child ask the nurse, Should we set rules for our child as part of a discipline plan? Which is an accurate response by the nurse? Wong's Nursing Care of Infants and Children 11th Edition a. It is best to delay the punishment if a rule is broken. b. The child is too young for rules. At this age, unrestricted freedom is best. c. It is best to set the rules and reason with the child when the rules are broken. d. Set clear and reasonable rules and expect the same behavior regardless of the circumstances. ANS: D Nurses can help parents establish realistic and concrete rules. Tclheearer the limits that ar e set and the more consistently they are enforced, the less need there is for disciplinary action. Delaying punishment weakens its intent. Children want and need limits. Unrestricted freedom is a threat to their security and safety. Reasoning involves explaining why an act is wrong and is usually appropriate for older children, especially when moral issues are involved. However, young children cannot be expected to see the other side because of their egocentrism. DIF: Cognitive Level: Applying REF: MCS: 25 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 29. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed? a. We will try to preserve the adopted childs racial heritage. b. We are glad we will be getting full medical information when we adopt our child. c. We will make sure to have everyone realize this is our child and a member of the family. d. We understand strangers may make thoughtless comments about our child being different from us. ANS: B In international adoptions, the medical information the parents receive may be incomplete or sketchy; weight, height, and head circumference are often the only objective information present Wong's Nursing Care of Infants and Children 11th Edition in the childs medical record. Further teaching is needed if the parents expect full medical information. It is advised that parents who adopt children with different ethnic backgrounds do everything to preserve the adopted childrens racial heritage. Strangers may make thoughtless comments and talk about the children as though they were not members of the family. It is vital that family members declare to others that this is their child and a cherished member of the family. DIF: Cognitive Level: Applying REF: pp. 27-28 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 30. The school nurse understands that children are impacted by divorce. Which has the most impact on the positive outcome of a divorce? a. Age of the child b. Gender of the child c. Family characteristics d. Ongoing family conflict ANS: C Family characteristics are more crucial to the childs well-being during a divorce than specific child characteristics, such as age or sex. High levels of ongoing family conflict are related to problems of social development, emotional stability, and cognitive skills for the child. DIF: Cognitive Level: Understanding REF: MCS: 29 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 31. The nurse is discussing parenting in reconstituted families with a new stepparent. The nurse is aware that the new stepparent understands the teaching when which statement aisdme? a. Iram glad the e will be no disruption in my lifestyle. Wong's Nursing Care of Infants and Children 11th Edition MSC: Client Needs: Psychosocial Integrity 3. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.) a. Regressive behavior b. Fear of abandonment c. Fear regarding the future d. Blame themselves for the divorce e. Intense desire for reconciliation of parents ANS: A, B, D Feelings and behaviors of early preschool children related to divorce include regressive behavior, fear of abandonment, and blaming themselves for the divorce. Fear regarding the future and intense desire for reconciliation of parents is a reaction later school-age children have to divorce. DIF: Cognitive Level: Understanding REF: MCS: 29 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 4. Which describe the feelings and behaviors of adolescents related to divorce? (Select all that apply.) a. Disturbed concept of sexuality b. May withdraw from family and friends c. Worry about themselves, parents, or siblings d. Expression of anger, sadness, shame, or embarrassment e. Engage in fantasy to seek understanding of the divorce ANS: A, B, C, D Feelings and behaviors of adolescents related to divorce include a disturbed concept of sexuality; withdrawing from family and friends; worrying about themselves, parents, and siblings; and Wong's Nursing Care of Infants and Children 11th Edition expressions of anger, sadness, shame, and embarrassment. Engaging in fantasy to seek understanding of the divorce is a reaction by a child who has preconceptual cognitive processes, not the formal thinking processes adolescents have. Chapter 3.Hereditary Influences on Health Promotion of the Child and Family MULTIPLE CHOICE 1. Which genetic term refers to a person who possesses one copy of an affected gene and one copy of an unaffected gene and is clinically unaffected? a. Allele b. Carrier c. Pedigree d. Multifactorial ANS: B An individual who aisrraiecr is asymptomatic but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expressions of genes at a different locus. A pedigree is a diagram that describes family rlaetionships, ge nder, disease, status, or other relevant information about a family. Multifactorial describes a complexrianctteion of both genetic and environmental factors that produce an effect on the individual. DIF: Cognitive Level: Understanding REF: MCS: 46 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 2. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome afterocmhrosome breakage? a. Trisomy b. Monosomy c. Translocation Wong's Nursing Care of Infants and Children 11th Edition d. Nondisjunction ANS: C Translocation is the transfer of all or part of a chromosome to a different chromosome after chromosome breakage. It can be balanced, producing no phenotypic effects, or unbalanced, producing severe or lethal effects. Trisomy is an abnormal number of chromosomes caused by the presence of an extra chromosome, which is added to a given chromosome pair and results in a total of 47 chromosomes per cell. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction is the failure of homologous chromosomes or chromatids to separate during mitosis or meiosis. DIF: Cognitive Level: Understanding REF: MCS: 48 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 3. Which is a birth defect or disorder that occurs as a new case in a family and is not inherited? a. Sporadic b. Polygenic c. Monosomy d. Association ANS: A Sporadic describes a birth defect previously unidentified in a family. It is not inherited. Polygenic inheritance involves the inheritance of many genes at separate loci whose combined effects produce a given phenotype. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. A nonrandom cluster of malformations without a specific cause is an association. DIF: Cognitive Level: Understanding REF: MCS: 48 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance Wong's Nursing Care of Infants and Children 11th Edition TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Parents ask the nurse about the characteristics of autosomal dominant inheritance. Which statement is characteristic of autosomal dominant inheritance? a. Females are affected with greater frequency than males. b. Unaffected children of affected individuals will have affected children. c. Each child of a heterozygous affected parent has a 50% chance of being affected. d. Any child of two unaffected heterozygous parents has a 25% chance of being affected. ANS: C In autosomal dominant inheritance, only one copy of the mutant gene is necessary tohceause t disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for the disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not skip a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for ethdisorder. I n autosomal recessive inheritance, any child of two unaffected heterozygous parents has a 25% chance of being affected. DIF: Cognitive Level: Applying REF: MCS: 57 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. Parents ask the nurse about the characteristics of autosomal recessive inheritance. Which is characteristic of autosomal recessive inheritance? a. Affected individuals have unaffected parents. b. Affected individuals have one affected parent. c. Affected parents have a 50% chance of having an affected child. d. Affected parents will have unaffected children. ANS: A Wong's Nursing Care of Infants and Children 11th Edition Parents who are carriers of a recessive gene are asymptomatic. For a child tofbeectaefd, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic but can have affected children. Inoamutaolsrecessive inheritance, ethre is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance, affected parents can have unaffected children. DIF: Cognitive Level: Applying REF: MCS: 62 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Health P romotion and Maintenance 10. Which is characteristic of X-linked recessive inheritance? a. There are no carriers. b. Affected individuals are principally males. c. Affected individuals are principally females. d. Affected individuals will always have affected parents. ANS: B In X-linked recessive disorders, the affected individuals are usually em.aWl ith rveectersasiits, usually two copies of the gene are needed to produce the effect. Because the male only hXas one chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disordXercs. The hromosome that does not have the recessive gene will produce the normal protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected. DIF: Cognitive Level: Understanding REF: MCS: 64 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 11. A fthaer with a n X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. Which response should the nurse make? Wong's Nursing Care of Infants and Children 11th Edition a. Male children will be carriers. b. All male children will be affected. c. None of the sons will have the disorder. d. It cannot be determined without more data. ANS: C When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes only his Y chromosome (not the X chromosome) to his sons. Therefore, none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question. DIF: Cognitive Level: Applying REF: MCS: 64 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 12. The inheritance of which is X-linked recessive? a. Hemophilia A b. Marfan syndrome c. Neurofibromatosis d. Fragile X syndrome ANS: A Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an X- linked trait. DIF: Cognitive Level: Understanding REF: MCS: 64 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance Wong's Nursing Care of Infants and Children 11th Edition c. Because the parents have one affected child, the next three children should be unaffected. d. Because the parents have one affected child, the next child is four times more likely to be affected. ANS: A Each pregnancyhheas t same risks for eacnteadffchild. Because an odds ratio reflects the risk, this does not change over time. The statement by the genetic counselor refers to a probability. This does not change over time. The statement Because the parents have one affected child, the next dchiil s four mti es more likely t ofbeectaefd doe s not lrecft au tosomal recessive inheritance. DIF: Cognitive Level: Analyzing REF: MCS: 57 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. A couple expecting their first child has a positive family history for several congenital defects and disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which should the nurse consider when counseling the couple? a. The couple should be encouraged to have recommended diagnostic testing. b. The couple needs counseling regarding advantages and disadvantages of pregnancy termination. c. Diagnostic testing is required by law in this situation. d. Diagnostic testing is of limited value if termination of pregnancy is not an option. ANS: A The benefits of prenatal diagnostic testing extend beyond decisions concerning abortion. If the child has congenital disorders, decisions can be made about fetal surgery if indicated. In addition, if the child is expected to require neonatal intensive care at birth, the mother is encouraged to deliver at a level III neonatal center. The couple is counseled about the advantages and disadvantages of prenatal diagnosis, not pregnancy termination, although the family cannot Wong's Nursing Care of Infants and Children 11th Edition be forced to have prenatal testing. The information gives the parents time to grieve and plan for their child if congenital disorders are present. If the child is free of defects, then the parents are relieved of a major worry. DIF: Cognitive Level: Applying REF: MCS: 71 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 18. Parents ask the nurse if there was something that should have been done during the pregnancy to prevent their childs cleft lip. Which statement should the nurse give as a response? a. This is a type of deformation and can sometimes be prevented. b. Studies show that taking folic acid during pregnancy can prevent this defect. c. This is a genetic disorder and has a 25% chance of happening with each pregnancy. d. The malformation occurs at approximately 5 weeks of gestation; there is no known way to prevent this. ANS: D Cleft lip, an example of a malformation, occurs at approximately 5 weeks of gestation when the developing embryo naturally has two clefts in the area. There is no known way to prevent this defect. Deformations are often caused by extrinsic mechanical forces on normally developing tissue. Club foot is an example of a deformation often caused by uterine constraint. Cleft lip is not a genetic disorder; the reasons for this occurring are still unknown. Taking folic acid during pregnancy can help to prevent neural tube disorders but not cleft lip defects. DIF: Cognitive Level: Applying REF: MCS: 49 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance Wong's Nursing Care of Infants and Children 11th Edition 19. The nurse is teaching parents of a child with cri du chat syndrome about this disorder. The nurse understands parents understand the teaching if they make which statement? a. This disorder is very common. b. This is an autosomal recessive disorder. c. The crying pattern is abnormal and catlike. d. The child will always have a moon-shaped face. ANS: C Typical of this disease is a crying pattern that is abnormal and catlike. Cri du chat, or cats cry, syndrome is a rare (one in 50,000 live births) chromosome deletion syndrome, not autosomal recessive, resulting from loss of the small arm of chromosome 5. In early infancy this syndrome manifests with a typical but nondistinctive facial appearance, often a moon-shaped face with wide-spaced eyes (hypertelorism). As the child grows, this feature is progressively diluted, and by age 2 years, the child is indistinguishable from age-matched control participants. DIF: Cognitive Level: Applying REF: pp. 54-55 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 20. The nurse is reviewing a clients prenatal history. Which prescribed medication does the nurse understand is not considered a teratogen and prescribed during pregnancy? a. Phenytoin (Dilantin) b. Warfarin (Coumadin) c. Isotretinoin (Accutane) d. Heparin sodium (Heparin) ANS: D Teratogens, agents that cause birth defects when present in the prenatal environment, account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens Wong's Nursing Care of Infants and Children 11th Edition a. Ambiguous genitalia b. Prenatal growth retardation c. An abnormally large tongue d. Legs and arms significantly shorter than torso ANS: A A newborn diagnosed with congenital adrenal hyperplasia can have ambiguous genitalia or virilization of female external genitalia caused by elevated androgen levels. Prenatal growth retardation is present with Bloom syndrome. An abnormally large tongue is seen with Beckwith- Wiedemann syndrome. Legs and arms significantly shorter than torso are seen with achondroplasia. DIF: Cognitive Level: Analyzing REF: MCS: 59 TOP: Nursing Process: Assessment :MISC ntegrated Process: Physiological Itengrity 25. Parents of a child with hemophilia A ask the nurse, What is the deficiency with this disorder? Which correct response should the nurse make? a. Hemophilia A has a deficiency in red blood cells. b. Hemophilia A has a deficiency in platelets. c. Hemophilia A has a deficiency in factor IX. d. Hemophilia A has a deficiency in factor VIII. ANS: D Hemophilia A is deficient in factor VIII. Glucose-6-phosphate dehydrogenase (G6PD) deficiency shows low red blood cells (hemolytic anemia). Immunosuppression may be the cause of a deficient number of platelets. Hemophilia B is deficient in factor IX. DIF: Cognitive Level: Applying REF: MCS: 60 TOP: Integrated Process: Teaching/Learning Wong's Nursing Care of Infants and Children 11th Edition MSC: Client Needs: Health Promotion and Maintenance 26. A child with Prader-Willi syndrome has been hospitalized. Which assessment findings does the nurse expect with this syndrome? a. Nonverbal b. Insatiable hunger c. Abnormal, puppetlike gait d. Paroxysms of inappropriate laughter ANS: B Prader-Willi syndrome is characterized by insatiable hunger that can lead to morbid obesity in childhood. Abnormal, puppetlike gait, paroxysms of inappropriate laughter, and nonverbal are characteristics seen in Angelman syndrome. DIF: Cognitive Level: Analyzing REF: MCS: 66 TOP: NursoicnegssP:rAssessment :MIS C ntegrated Process: Physiological Itengrity 27. Which ethnic group is at risk for Tay-Sachs disease? a. Black African b. Mediterranean c. Ashkenazi Jewish d. Southern and Southeast Asian ANS: C The Ashkenazi Jewish ethnic group is at higher risk for Tay-Sachs disease. The black African, Mediterranean, and Southern and Southeast Asian ethnicities are at higher risk for sickle cell anemia disease. DIF: Cognitive Level: Understanding REF: MCS: 78 Wong's Nursing Care of Infants and Children 11th Edition TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. A child has been found to have a deficiency in 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Which condition is this child at risk for? a. Increased uric acid b. Hypercholesterolemia c. Increased phenylketones d. Altered oxygen transport ANS: B HMG-CoA leads to a disruption of metabolic feedback mechanism and accumulation of end product (cholesterol) with the resulting condition of hypercholesterolemia. DIF: Cognitive Level: Analyzing REF: MCS: 48 TOP: NursoicnegssP:rAssessment :MIS C ntegrated Process: Physiological Itengrity 29. Phenylketonuria is a genetic disease that results in the bodys inability to correctly metabolize which? a. Glucose b. Thyroxine c. Phenylalanine d. Phenylketones ANS: C Phenylketonuria is an inborn error of metabolism caused by a deficiency eonr caebs of the enzyme needed to metabolize the essential amino acid phenylalanine. Individuals with this disorder can metabolize glucose. Thyroxine is one of the principal hormones secreted by the thyroid gland. Phenylketones are metabolites of phenylalanine excreted in the urine. DIF: Cognitive Level: Understanding REF: MCS: 61 Wong's Nursing Care of Infants and Children 11th Edition Characteristics of autosomal dominant inheritance include the phenotype appears in consecutive generations, males and females are equally affected, and children of eancteadff pa rent have a 50% chance of being affected. A carriertsetand parents who have affected children are usually asymptomatic are characteristic of autosomal recessive inheritance. DIF: Cognitive Level: Analyzing REF: MCS: 55 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 3. The nurse is reviewing the characteristics of autosomal recessive inheritance. Which are true about these characteristics? (Select all that apply.) a. Most affected persons are males. b. Males and females are equally affected. c. All daughters of an affected male are carriers. d. Carrier parents have a 25% chance of producing an affected child. e. Carrier parents have a 50% chance of producing a carrier child in each pregnancy. ANS: B, D, E Characteristics of autosomal recessive inheritance include males and females are equally affected, carrier parents have a 25% chance of ipnrgoduc anfaefcted child, and car rier parents have a 50% chance of producing a carrier child in each pregnancy. Most affected persons who are males and all daughters of aneacftfed m ale are carriers are characteristics of X-linked recessive inheritance. DIF: Cognitive Level: Analyzing REF: MCS: 57 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Which are signs and symptoms the nurse should assess in the newborn that can indicate an inborn error of metabolism? (Select all that apply.) a. Jaundice b. Strabismus Wong's Nursing Care of Infants and Children 11th Edition c. Poor feeding d. Acrocyanosis e. Metabolic acidosis ANS: A, C, E Signs of inborn errors of metabolism include jaundice, poor feeding, and metabolic acidosis. Strabismus and acrocyanosis are normal findings in the newborn. Chapter 4.Communication, Physical, and Developmental Assessment of the Child and Family MULTIPLE CHOICE 1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? a. Introduce him- or herself. b. Make the family comfortable. c. Give assurance of privacy. d. Explain the purpose of the interview. ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in anoennmviernt as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality. DIF: Cognitive Level: Applying REF: MCS: 91 TOP: Integrated Process: Communication and Documentation Wong's Nursing Care of Infants and Children 11th Edition MSC: Client Needs: Health Promotion and Maintenance 2. Which is considered a block to effective communication? a. Using silence b. Using clichs c. Directing the focus d. Defining the problem ANS: B Using stereotyped comments or clichs can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for nressepsoto questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintaintaiorneslhaip w ith the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention. DIF: Cognitive Level: Applying REF: MCS: 94 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 3. Which is the single most important factor to consider when communicating with children? a. Presence of the childs parent b. Childs physical condition c. Childs developmental level d. Childs nonverbal behaviors ANS: C Wong's Nursing Care of Infants and Children 11th Edition confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent. DIF: Cognitive Level: Understanding REF: MCS: 96 | MCS: 97 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate? a. Initiate a game of peek-a-boo. b. Ask the infants father to place the infant on the examination table. c. Talk softly to the infant while taking him from his father. d. Undress the infant while he is still sitting on his fathers lap. ANS: A Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination. DIF: Cognitive Level: Applying REF: MCS: 97 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 8. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which? a. Ask her why she wants to know. b. Determine why she is so anxious. c. Explain in simple terms how it works. Wong's Nursing Care of Infants and Children 11th Edition d. Tell her she will see how it works as it is used. ANS: C School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur. DIF: Cognitive Level: Applying REF: MCS: 96 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful? a. Recommend that the child keep a diary. b. Provide supplies for the child to draw a picture. c. Suggest that the parent read fairy tales to the child. d. Ask the parent if the child is always uncommunicative. ANS: B Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childrens inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative. Wong's Nursing Care of Infants and Children 11th Edition DIF: Cognitive Level: Applying REF: MCS: 99 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 10. Which data should be included in a health history? a. Review of systems b. Physical assessment c. Growth measurements d. Record of vital signs ANS: A A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination. DIF: Cognitive Level: Remembering REF: MCS: 100 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 11. The nurse is taking a health history of an adolescent. Which best describes how ethchief complaint should be determined? a. Request a detailed listing of symptoms. b. Ask the adolescent, Why did you come here today? c. Interview the parent away from the adolescent to determine the chief complaint. d. Use what the adolescent says to determine, in correct medical terminology, what the problem is. ANS: B The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the Wong's Nursing Care of Infants and Children 11th Edition DIF: Cognitive Level: Applying REF: MCS: 102 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 15. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which? a. Lacking in protein b. Indicating they live in poverty c. Providing sufficient amino acids d. Needing enrichment with meat and milk ANS: C A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth. DIF: Cognitive Level: Applying REF: MCS: 106 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 16. Which parameter correlates best withemntesaosuf rem total muscle mass? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference ANS: D Wong's Nursing Care of Infants and Children 11th Edition Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the bodys fat content. DIF: Cognitive Level: Understanding REF: MCS: 122 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 17. The nurse is preparing tofpoermr a physical a esnstess m on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which? a. Appropriate because of childs age b. Appropriate, but the mother may be uncomfortable c. Inappropriate because of childs age d. Inappropriate because child is same sex as mother ANS: A It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, andepnatr s are responsible for thheaclar e decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination. DIF: Cognitive Level: Applying REF: MCS: 112 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 18. With the tNioanal Center for Health S tatistics criteria, whichsbsoidnydema percentiles should indicate the patient is at risk for being overweight? a. 10th percentile b. 75th percentile Wong's Nursing Care of Infants and Children 11th Edition x (BMI)for-age Wong's Nursing Care of Infants and Children 11th Edition b. Buttocks c. Oral mucosa d. Palms and soles ANS: C Petechiae, small distinct pinpoint hemorrhages, fairceudltifto see in dark- skinned individuals unless they are in the mouth or conjunctiva. DIF: Cognitive Level: Understanding REF: MCS: 124 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Health Promotion and Maintenance 23. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action? a. Recheck head control at next visit. b. Teach the parents appropriate exercises. c. Schedule the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open. ANS: C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated. DIF: Cognitive Level: Applying REF: pp. 125-126 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 24. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action? Wong's Nursing Care of Infants and Children 11th Edition a. Ask the parent when the neck was injured. b. Refer for immediate medical evaluation. c. Continue assessment to determine the cause of the neck pain. d. Record head lag on the assessment record and continue the assessment of the child. ANS: B Hyperextension of the childs head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag. DIF: Cognitive Level: Analyzing REF: MCS: 125 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 25. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which? a. A normal finding b. A sign of a possible visual defect and a need for vision screening c. An abnormal finding requiring referral to an ophthalmologist d. A sign of small hemorrhages, which usually resolve spontaneously ANS: A A biarniltl, uniform re d reflex pisoartnanimt normal finding. It rules out many serious edcetfs of the cornea, aqueous chamber, lens, and vitreous chamber. DIF: Cognitive Level: Analyzing REF: MCS: 127 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 26. Which explains the importance of detecting strabismus in young children? Wong's Nursing Care of Infants and Children 11th Edition a. Color vision deficit may result. b. Amblyopia, a type of blindness, may result. c. Epicanthal folds may develop in the affected eye. d. Corneal light reflexes may fall symmetrically within each pupil. ANS: B By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes lazy, and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the ncoear l light reflex will not be symmetric for each eye. DIF: Cognitive Level: Understanding REF: MCS: 127 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 27. Which is the most frequently used test for measuring visual acuity? a. Snellen letter chart b. Ishihara vision test c. Allen picture card test d. Denver eye screening test ANS: A The Snellen letter chart, which consists of nlies of l etters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for lcdhrien ag es 2 years and older who are unable to use the Snellen letter chart. DIF: Cognitive Level: Understanding REF: MCS: 129 Wong's Nursing Care of Infants and Children 11th Edition DIF: Cognitive Level: Applying REF: MCS: 134 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 32. When assessing a preschoolers chest, what should the nurse expect? a. Respiratory movements to be chiefly thoracic b. Anteroposterior diameter to be equal to the transverse diameter c. Retraction of the muscles between the ribs on respiratory movement d. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing ANS: D Movement of the chest wall should be symmetric bilaterally and coordinated with breathing. In children younger than 6 or 7 years, respiratory movement is principally abdominal or diaphragmatic. Tahneteroposterior a d m i eter is equal to the transverse diameter during infancy. As the child grows, the chest increases in the transverse direction, so that the anteroposterior diameter is less than the lateral diameter. Retractions of the muscles between the ribs on respiratory movement are indicative of respiratory distress. DIF: Cognitive Level: Applying REF: MCS: 135 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 33. When auscultating an infants lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as? a. Suggestive of chronic pulmonary disease b. Suggestive of impending respiratory failure c. An abnormal finding warranting investigation d. A normal finding in infants younger than 1 year of age ANS: C Wong's Nursing Care of Infants and Children 11th Edition Absent or diminished breath sounds are always an abnormal finding. Fluid, air, or solid masses in the pleural space all interfere with the conduction of breath sounds. Further data are necessary for diagnosis of chronic pulmonary disease or impending respiratory failure. Diminished breath sounds in certain segments of the lungs can alert the nurse to pulmonary areas that may benefit from chest physiotherapy. Further evaluation is needed in all age groups. DIF: Cognitive Level: Analyzing REF: MCS: 137 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 34. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular b. Bronchial c. Adventitious d. Bronchovesicular ANS: A This is the definition of vesicular breath sounds.yTahre e heard over the entire surface of the lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions, where the trachea and bronchi bifurcate. DIF: Cognitive Level: Understanding REF: MCS: 137 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 35. The nurse is assessing a childs capillary refill time. This can be accomplished by doing what? a. Inspect the chest. b. Auscultate the heart. Wong's Nursing Care of Infants and Children 11th Edition c. Palpate the apical pulse. d. Palpate the nail bed with pressure to produce a slight blanching. ANS: D Capillary refill time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary refill time. DIF: Cognitive Level: Applying REF: MCS: 139 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Health Promotion and Maintenance 36. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the kb-ac and-forth flow of blood? a. S1 and S2 b. S3 and S4 c. Murmur d. Physiologic splitting ANS: C Murmurs are the sounds thaa re produced inethhe art chambers or omraj earites from t he back- and-forth flow of blood. S1 and S2 are normal heart sounds. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves. S3 is a normal heart sound sometimes heard in children. S4airserly he ard as a normal heart sound. If it is heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding. DIF: Cognitive Level: Understanding REF: MCS: 140 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance Wong's Nursing Care of Infants and Children 11th Edition When using an interpreter, the nurse should communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions. Questions should be posed one at a time to elicit only one answer at a time. Medical jargon should be avoided whenever possible. The nurse should avoid discussing the familys needs with the interpreter in English because some family members may understand some English. DIF: Cognitive Level: Applying REF: MCS: 94 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 41. Which action should the nurse implement when taking an axillary temperature? a. Take the temperature through one layer of clothing. b. Add a degree to the result when recording the temperature. c. Place the tip of the thermometer under the arm in the center of the axilla. d. Hold the childs arm away from the body while taking the temperature. ANS: C The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The childs arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method. DIF: Cognitive Level: Applying REF: MCS: 119 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 42. The nurse is aware that skin turgor best estimates what? a. Perfusion b. Adequate hydration c. Amount of body fat Wong's Nursing Care of Infants and Children 11th Edition d. Amount of anemia ANS: B Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia. DIF: Cognitive Level: Understanding REF: MCS: 125 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 43. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences? a. The parent feels inferior to the nurse. b. The parent is showing respect for the nurse. c. The parent is embarrassed to seek health care. d. The parent feels responsible for her childs illness. ANS: B In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurses 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: Analyzing REF: MCS: 93 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.) a. Ashen gray areas Wong's Nursing Care of Infants and Children 11th Edition b. A well-defined light reflex c. A small, round, concave spot near the center of the drum d. The tympanic membrane is a nontransparent grayish color e. A whitish line extending from the umbo upward to the margin of the membrane ANS: B, C, E Normal findings include the light reflex and bony landmarks. The light reflex is a fairly well- defined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation. DIF: Cognitive Level: Understanding REF: MCS: 132 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Physiological Integrity 2. The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) a. Wheezes b. Crackles c. Vesicular d. Bronchial e. Bronchovesicular ANS: C, D, E Normal breath sounds are classified as vesicular, bronchovesicular, or obrnchial. W heezes or crackles are abnormal or adventitious sounds. DIF: Cognitive Level: Applying REF: MCS: 137 Wong's Nursing Care of Infants and Children 11th Edition c. Using clichs d. Defending a situation e. Using open-ended questions ANS: A, C, D Blocks to communication include socializing, using clichs, and defending a situation. Use of silence and using open-ended questions are therapeutic communication techniques. Chapter 5.Pain in Children: Significance, Assessment, and Management Strategies MULTIPLE CHOICE 1. Which is the most consistent and commonly used data for assessment of pain in infants? a. Self-report b. Behavioral c. Physiologic d. Parental report ANS: B Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not oabdleistinguish between phy sical responses to pain and other forms of streresns.taPlareport without a s tructured tool maycncoutrately reflec t the degree of discomfort. DIF: Cognitive Level: Understanding REF: MCS: 152 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group? Wong's Nursing Care of Infants and Children 11th Edition a. No hurt. b. Red pain. c. Zero hurt. d. Least pain. ANS: A No hurt is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. Least pain is less concrete than no hurt. DIF: Cognitive Level: Applying REF: MCS: 154 TOP: NursoicnegssP:rAssessment :MCS C lient Needs: Physiological Integrity 3. What is an important consideration when using the FACES pain rating scale with children? a. Children color the face with the color they choose to best describe their pain. b. The scale can be used with most children as young as 3 years. c. The scale is not appropriate for use with adolescents. d. The FACES scale is useful in pain assessment but is not as accurate as physiologic responses. ANS: B The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The childs estimate of the pain should be used. The physiologic measures may not reflect more long-term pain. DIF: Cognitive Level: Applying REF: MCS: 154 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity Wong's Nursing Care of Infants and Children 11th Edition 4. What describes nonpharmacologic techniques for pain management? a. They may reduce pain perception. b. They usually take too long to implement. c. They make pharmacologic strategies unnecessary. d. They trick children into believing they do not have pain. ANS: A Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the childs pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the childs experience with mild pain, but the child will still know the discomfort was present. DIF: Cognitive Level: Analyzing REF: pp. 163-164 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 5. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain? a. Tactile stimulation b. Commercial warm packs c. Doing procedure during infant sleep d. Oral sucrose and nonnutritive sucking ANS: D Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow Wong's Nursing Care of Infants and Children 11th Edition MSC: Client Needs: Physiological Integrity 9. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurses response should be based on which characteristic about preterm infants pain? a. They may react to painful stimuli but are unable to remember the pain experience. b. They perceive and react to pain in much the same manner as children and adults. c. They do not have the cortical and subcortical centers that are needed for pain perception. d. They lack neurochemical systems associated with pain transmission and modulation. ANS: B Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as childrtesn. Panredteardmuli nfants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, andohnoarlmand metabolic changes.qAudate are necessary to decrease the stress response. DIF: Cognitive Level: Analyzing REF: MCS: 153 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiological Integrity e analgesia and anesthesia 10. A preterm infant has just been admitted to the neonatal intensive care unit. The infants parents ask the nurse about tahneessia and analgesia when painful procedures are necessary. What should the nurses explanation be? a. Nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli. Wong's Nursing Care of Infants and Children 11th Edition b. The risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief. c. Neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences. d. Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. ANS: D Pain pathways and cnheuemroical sys emst associated w th ip ain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, andohnoarlmand metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates. DIF: Cognitive Level: Analyzing REF: MCS: 185 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiological Integrity 11. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which? a. Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure. b. Use a combination of fentanyl and midazolam for conscious sedation. c. Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure. d. Apply a transdermal fentanyl (Duragesic) patch immediately before the procedure. ANS: B A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes Wong's Nursing Care of Infants and Children 11th Edition after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is aneecftfive topical analgesic agent w hen applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For rthoicsepdure, sys emitc analgesia is required. T ransdermal fentanyl patches are useful for continuous pain control, not rapid pain control. DIF: Cognitive Level: Analyzing REF: MCS: 185 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. What is a significant common side effect that occurs with opioid administration? a. Euphoria b. Diuresis c. Constipation d. Allergic reactions ANS: C Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus. DIF: Cognitive Level: Remembering REF: MCS: 171 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 13. The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first? a. Administer naloxone (Narcan). b. Discontinue the IV infusion.