TB-Chapter 22 Health Care Adaptations for the Child and Family PDF

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Test Bank for Chapter 22 - Med Surg for Nursing LVN/LPN...

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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK

TestBank-IntroductiontoMaternityandPediatricNursing8e(byLeifer)

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Chapter22:HealthCareAdaptationsfortheChildandFamily MULTIPLECHOICE 1.Whatisthebestpulselocationforthenursetousewhenassessingthepulserateona12-month-oldinfant? a.Brachial b.Apical c.Radial d.Femoral ANS:B Apicalpulsesareadvisedforchildrenunderage5years. DIF:CognitiveLevel:KnowledgeREF:Page502 TOP:PhysicalAssessmentKEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation 2.Thenursepreparingtoadministermedicationtoa2-month-oldinfantdiscoversthereisnoIDbraceleton thechild.Whatshouldbethenextactionbythenurse? a.Givethemedicationafterconfirmingthechildsnamefromthefootofthecrib. b.Askthechargenursetogivethemedicine. c.Confirmtheidentitywiththechargenurse,makeanewbracelet,andgivethemedicine. d.DelaythemedicationuntiltheadmissionsofficecansupplyanewIDbracelet. ANS:C Afterconfirmationofthechildsidentitywiththechargenurseandmakinganewbracelet,themedicationcan besafelygiven.Allpatientsshouldbeidentifiedbeforetreatment. DIF:CognitiveLevel:ApplicationREF:Page497 NURSINGTB.COM OBJ:2TOP:IDBraceletsKEY:NursingProcessStep:Implementation MSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControl 3.Thenurseinstructedanadolescentfemaleaboutcollectingaclean-catchurinespecimen.Whatstatement madebytheadolescentledthenursetodeterminesheunderstoodtheinstructions? a.Ishouldwashmyperineumwithsoapandwater,thenbegintourinate. b.IcleantheperineumfromfronttobackwithanantisepticwipebeforeIurinate. c.Illcollectthefirststreamofurineinasterilecontainer. d.Iwilldiscardthefirstvoidandcollectafreshlyvoidedspecimen30minuteslater. ANS:B Toobtainaclean-catchspecimen,theperineumiscleansedwithanantisepticwipefromfronttoback. DIF:CognitiveLevel:AnalysisREF:Page508 TOP:CollectingSpecimensKEY:NursingProcessStep:Evaluation MSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControl 4.Whichstrategymightthenurseusewhenadministeringoralmedicationstoayoungchildwhoisreluctant? a.Mixthemedicationwithchocolatemilk. b.Tellthechildthatthemedicationiscandy. c.Givethemedicationquicklyifthechildiscrying. d.Offerthechildfruitjuiceafterthemedicationisswallowed. ANS:D Thenursecanofferachaserofwater,fruitjuice,oracarbonatedbeverageafterthemedicationhasbeen swallowed.Medicationsshouldnotbemixedwithfoodordrinkswithimportantnutrientssuchasmilk becausethechildmaydevelopdistasteforit. DIF:CognitiveLevel:ApplicationREF:Page512 TOP:AdministeringOralMedicationsKEY:NursingProcessStep:Implementation

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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK TestBank-IntroductiontoMaternityandPediatricNursing8e(byLeifer) 201

MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 5.Aparenttellsthenurse,Imnotsurehowtogivethismedicinetomyinfant.Howwouldthenurseteachthe parenttobestadministeranoralsuspension? a.Pourthemedicationintoasmallcupandallowingtheinfanttodrinkit. b.Placethemedicationinanippleandhavingtheinfantsuckthenipple. c.Useanoralsyringeandplacingthemedicationinthesideoftheinfantsmouth. d.Administerthemedicationwithadropperontothebackoftheinfantstongue. ANS:C Anoralsyringeisausefuldeviceformeasuringsmallquantitiesofmedicationsforinfants.Thesyringeis placedmidwayback,atthesideofthemouth. DIF:CognitiveLevel:ApplicationREF:Page513 TOP:AdministeringOralMedicationsKEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 6.Gentamicineardropsareprescribedfora4-year-oldchild.Howwouldthenursepositiontheauriclewhen administeringtheeardrops? a.Upandback b.Downandback c.Upandout d.Downandout ANS:A Forchildren3yearsofageandolder,theauricleisgentlypulledupwardandbackwardtostraightenthecanal. DIF:CognitiveLevel:ApplicationREF:Page514 OBJ:10TOP:AdministeringEarDrops KEY:NursingProcessStep:Implementation NURSINGTB.COM MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 7.Whyisatympanicthermometerconsideredmoreaccuratethanothertypesofthermometers? a.Thethermometerprobeisbluntandwide. b.Ittakesabrieftimetoregister. c.Thetympanicmembranesharescirculationwiththehypothalamus. d.Thetympanicmembraneandthebrainhavethesametemperature. ANS:C Theaccuracyofthetympanicthermometerisattributabletothefactthatthetympanicmembraneandthe hypothalamussharethesamecirculation. DIF:CognitiveLevel:KnowledgeREF:Page506 TOP:TympanicThermometerKEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation 8.Whichinterventioniscorrectwhenanurseisadministeringagastrostomyfeedingbygravity? a.Discardtheresidualandincreasethevolumeoffeedingbytheamountofresidual. b.Flushthegastrostomytubewith2to4ouncesofwaterbeforethefeeding. c.Refillthesyringewithformulaafterithascompletelyemptied. d.Positionthechildontherightsideafterafeeding. ANS:D Topreventregurgitationandaspiration,thechildisplacedintheFowlerspositionorontherightsideto promotegastricemptyingafteragastrostomytubefeeding. DIF:CognitiveLevel:ApplicationREF:Page526 OBJ:13TOP:EnteralFeedings KEY:NursingProcessStep:Implementation

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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK TestBank-IntroductiontoMaternityandPediatricNursing8e(byLeifer) 202

MSC:NCLEX:PhysiologicalIntegrity:ReductionofRisk 9.Whichrestraintismostappropriatefortheinsertionofanintravenouslineinascalpveinofaninfant? a.Mummy b.Clovehitch c.Jacket d.Elbow ANS:A Amummyrestraintwouldbeusedtorestrainaninfantforinsertionofanintravenouslineinascalpvein. DIF:CognitiveLevel:ComprehensionREF:Page499 OBJ:12TOP:RestrainingtheInfant KEY:NursingProcessStep:Implementation MSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControl 10.Howoftenshouldachildwhohasacontinuousintravenousinfusionshouldbeassessed? a.Hourly b.Every2hours c.Every3hours d.Every4hours ANS:A Thenursemustassesshourlyanintravenousinfusionforcomplications,suchasinflammationandinfiltration. DIF:CognitiveLevel:KnowledgeREF:Page516 TOP:AdministeringParenteralMedications KEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:ReductionofRisk NURSINGTB.COM

11.Theprescriptionfora4-month-oldispenicillinG150,000unitsintramuscularlybid.Thedrugissupplied asaunitdoseof600,000unitsina5-mLvial.Howmanymilliliters(mL)shouldthenurseprovide? a.1.25 b.1.4 c.1.6 d.1.8 ANS:B 600,000_mL 5mL150,000=1.25mL Thisdosewouldhavetobegivenindivideddosesasonly0.5to1mLshouldbeinjectedinonesiteonan infant. DIF:CognitiveLevel:AnalysisREF:Page520 OBJ:9TOP:AdministeringInjections KEY:NursingProcessStep:Planning MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 12.Whichinterventionwillthenurseimplementwhensuctioningatracheostomy? a.Suctionfortwotothreebreaths. b.Clearthecatheterwithwateraftersuctioningforreuse. c.Applysuctionfornomorethan15seconds. d.Establisharegularscheduleforsuctioning. ANS:C Suctioningshouldbelimitedto15seconds. DIF:CognitiveLevel:ApplicationREF:Page527

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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK TestBank-IntroductiontoMaternityandPediatricNursing8e(byLeifer) 203

TOP:RespirationKEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 13.Whatemergencyactionshouldbeimplementedforairwayobstructionintheinfant? a.Sixto10midsternalthrusts b.Fivebackblowsfollowedbyfivechestthrusts c.Fivechestthrustsfollowedbyfivebackblows d.Abdominalthrustsuntiltheobjectisexpelled ANS:B Fivebackblowsfollowedbyfivechestthrustsistheappropriateinterventionforairwayobstructioninthe infant. DIF:CognitiveLevel:KnowledgeREF:Page530 TOP:ManagementofAirwayObstruction KEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity:ReductionofRisk 14.A4-year-oldaskstearfullyiftheIMinjectionwillhurt.Whatisthenursesmosteffectiveresponse? a.No.Itisoverbeforeyouknowit. b.Yes.Itwillstingalittle. c.No.Wouldyouliketoseethesyringe? d.Yes.YourmomandIaregoingtoholdyoutohelpyoubestill. ANS:B Truthfulanswerswillgiveachildarealisticexpectationandhelpestablishtrustinthenurse. DIF:CognitiveLevel:ApplicationREF:Page515 TOP:PreparationforanIMInjectionKEY:NursingProcessStep:Implementation MSC:NCLEX:PsychosocialIntegrity:CopingandAdaptation NURSINGTB.COM 15.WhereisthebestsiteforgivinganIMinjectiontoa15-month-oldchild? a.Ventroglutealmuscle b.Dorsoglutealmuscle c.Deltoidmuscle d.Vastuslateralismuscle ANS:D Thevastuslateralismuscleisfreeofmajorbloodvesselsandnervesandcanbeusedinchildrenofanyage. DIF:CognitiveLevel:ApplicationREF:Page514 TOP:AdministeringInjectionsKEY:NursingProcessStep:Planning MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 16.Whatfactordoesthenurseexplainaffectstheinfantsphysiologicalresponsetomedications? a.Fastermetabolismintheliver b.Slowerintestinaltransit c.Immaturekidneyfunction d.Increasedsecretionofhydrochloricacid ANS:C Immaturekidneyfunctionpreventseffectiveexcretionofdrugsfromthebodyininfantslessthan1yearof age. DIF:CognitiveLevel:ComprehensionREF:Page511 TOP:PhysiologicalResponsestoMedication KEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity

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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK TestBank-IntroductiontoMaternityandPediatricNursing8e(byLeifer) 204

17.Whatinterventionshouldthenurseimplementaftertopicaladministrationofhydrocortisonecreamtothe buttocksandabdomenofaninfant? a.Diapertheinfantsnuglywithadisposablediaper. b.Covertheareawithatransparentdressing. c.Applyaclothdiaper. d.Placetheinfantonaplasticpad,undiapered. ANS:C Plasticcoveringsincreasetheabsorptionofdrugs.Thediapershouldbecloth,ortheinfantshouldbeleft undiaperedonaclothpad. DIF:CognitiveLevel:ApplicationREF:Page511 TOP:RapidAbsorptionofDrugKEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity:ReductionofRisk 18.Whichobservationonenteringthehospitalroomletsthenurseknowthatthereisaneedfortheparentsto receivesafetyeducationtopreventunintentionalinjury? a.Theblanketisnottuckedintothemattress. b.Diapersandwipesarestackedatthefootofthecrib. c.Thecribsideislockedintheupposition. d.Pillowsarestackedonthebedsidetable. ANS:B Disposablediapersandsuppliesmustbekeptoutoftheinfantsreachtopreventaccidentalsuffocation. DIF:CognitiveLevel:AnalysisREF:Page498 OBJ:2TOP:EssentialSafetyMeasures KEY:NursingProcessStep:Evaluation MSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControl NURSINGTB.COM

19.A9-year-oldchildispreparingforalumbarpuncture.Whatpositionwillthenurseexplainthechildwill assumeforthisprocedure? a.Onyourstomachwithyourheadturnedtotheside. b.Onyourside,keepingthelegsbentandtheheadarchedback. c.Onyourbackwithyourlegsextendedstraightout. d.Onyoursidewiththekneesbentandtheheadclosetotheknees. ANS:D Thechildispositionedonhisorhersidewiththekneesflexed,andtheheadisbroughtdownclosetothe flexedknees. DIF:CognitiveLevel:ApplicationREF:Page510 OBJ:8TOP:CollectingSpecimensLumbarPuncture KEY:NursingProcessStep:Implementation MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 20.Thenurseiscaringfora4-year-oldchild.Whatwillthenurseexpectthechildsdailyurinaryoutputtobe? a.400to500mL b.500to600mL c.600to700mL d.700to1000mL ANS:C Theaveragedailyexcretionofurinefora4-year-oldchildis600to700mL. DIF:CognitiveLevel:KnowledgeREF:Page510 OBJ:4TOP:CollectingSpecimensUrineOutput KEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort

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21.Aninfantsdrydiaperweighs2.5grams.Thewetdiaperweighs47grams.Howwouldthenurserecordthe infantsurineoutput? a.47mL b.44.5mL c.43.5mL d.40.5mL ANS:B Urineoutputisdeterminedbycalculatingthedifferenceinweightbetweenthewetdiaperandadrydiaper. Onegramisequivalenttoonemilliliterofoutput.472.5=44.5grams=44.5mLofurine. DIF:CognitiveLevel:AnalysisREF:Page524 OBJ:4TOP:CollectingSpecimensUrineOutput KEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 22.Thenurseinstructsthemotherofa2-year-oldwhoistakingironsupplementsforanemiathatsomefoods reducetheabsorptionofiron.Whatwouldbethebestexampleprovidedbythenurse? a.Redmeat b.Green,leafyvegetables c.Acidicfruitjuices d.Eggyolks ANS:D Eggyolksandstarchesreducetheabsorptionofironinthedigestivetractandshouldbelimitedforpersons takinganironsupplement. DIF:CognitiveLevel:ApplicationREF:Page525 OBJ:2TOP:Food/DrugInteractions KEY:NursingProcessStep:Implementation NURSINGTB.COM MSC:NCLEX:PhysiologicalIntegrity:PharmacologicalTherapies 23.Thepediatricnursecompletesanassessmentonallpatientsassignedduringeveningshiftatthehospital. Whichpatientassessmentrequiresimmediateintervention? a.Toddlerwithanaxillarytemperatureof99F b.School-agechildwithwideningpulsepressure c.Infantpulserateof100beatsperminute d.Adolescentwitharespiratoryrateof28breathsperminute ANS:B AwideningpulsepressurecanindicateincreasedICP;thereforeitisthepriority.Anaxillarytemperatureof99 F,infantpulseof100bpm,andadolescentrespiratoryrateof28areexpectedassessments. DIF:CognitiveLevel:ApplicationREF:Page502 OBJ:5TOP:VitalsignsKEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 24.A15-year-oldpatientreturnstothepediatricunitfollowingalumbarpuncture.Whatinitialpositionwill thenursemaintainforthispatient? a.Leftside-lying b.Supine c.Prone d.Semi-Fowlers ANS:B Theadolescentmayavoidpostlumbarpunctureheadachebylyingflatforsometime. DIF:CognitiveLevel:ApplicationREF:Page510 TOP:LumbarPunctureKEY:NursingProcessStep:Implementation

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MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort MULTIPLERESPONSE 25.Informedconsentforaminorguaranteesthattheparentorlegalguardianunderstandswhataspect(s)ofa procedure?(Selectallthatapply.) a.Purposeoftheprocedure b.Risksassociatedwiththeprocedure c.Thatnosuitcanbebroughtfordamages d.Thatthedocumentmustbesignedandwitnessed e.Thatinformationwasgiven ANS:A,B,D,E Theinformedconsentestablishesthatthepatient,parent,orlegalguardianunderstandsthepurposeandrisks oftheprocedure.Italsoestablishesthatthepatient,parent,orlegalguardianunderstandswhattheyhavebeen told;thedocumentshouldbesignedandwitnessed. DIF:CognitiveLevel:ComprehensionREF:Page497 TOP:InformedConsentKEY:NursingProcessStep:Implementation MSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare 26.Whichspecificdrug(s)shouldbecheckedwithasecondlicensednursepriortoadministration?(Selectall thatapply.) a.Insulin b.Digoxin c.Vasodilators d.Calciumsalts e.Anticoagulants ANS:A,B,D,E NURSINGTB.COM Insulin,hypoglycemics,narcotics,digoxin,inotropicdrugs,anticoagulants,potassium,andcalciumsaltsall mustbecheckedbyalicensednursepriortoadministration. DIF:CognitiveLevel:ComprehensionREF:Page518 TOP:DrugAdministrationKEY:NursingProcessStep:Implementation MSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControl 27.A3-year-oldpatientisadmittedtothepediatricunitwithafeverof103F.Whichactionswillthenurse implement?(Selectallthatapply.) a.Assessrectaltemperatureevery4hours. b.AdministerAcetaminophenasordered. c.Assessskinturgor. d.Restrictfluids. e.Assesslevelofconsciousness. ANS:B,C,E Whenevaluatingthedegreeofillnessinafebrilechild,thenurseshouldassessandrecordresponseofthe childtocuddling,alertness,hydration,sociability,andqualityofcry.Aquiet,lethargicchildwhodoesnot respondreadilytotheenvironmentmaybeacutelyill.Becausedehydrationisacommonproblemininfants andchildren,skinturgorshouldbeassessed.Antipyreticsalsoprovidecomfortandmayaidinenablingthe childtoconsumefluids,lesseningtheriskofdehydration.Rectaltemperaturesarenotrecommendedfor pediatricpatients. DIF:CognitiveLevel:ApplicationREF:Page503 OBJ:6TOP:FeverKEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort 28.Whatshouldthenurseassesstodeterminethemethodoftransportationforapediatricpatient?(Selectall thatapply.)

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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK TestBank-IntroductiontoMaternityandPediatricNursing8e(byLeifer) 207

a.Age b.Race c.Vitalsigns d.Distancetotravel e.Levelofconsciousness ANS:A,D,E Themeansbywhichthechildistransportedwithintheunitandtootherpartsofthehospitaldependsonage, levelofconsciousness,andhowfarthechildmusttravel. DIF:CognitiveLevel:ComprehensionREF:Page499 TOP:ModesofTransportationKEY:NursingProcessStep:DataCollection MSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControl COMPLETION 29.Thenurseissearchingthroughseveralbloodpressurecuffstofindacuffthatistheappropriatesizeforher smallpatient.Thenurseselectsacuffthatcovers_____________ofthepatientsupperarm. ANS: twothirds Nomattertheageofthepatient,forthebloodpressurecufftoprovideanaccuratereadingitshouldcovertwo thirdsoftheupperarm.Asmallercuffwillgiveaninaccuratelyhighreadingandalargercuffwillgivean inaccuratelylowreading. DIF:CognitiveLevel:ApplicationREF:Page503 OBJ:4TOP:SelectionofBloodPressureCuff KEY:NursingProcessStep:DataCollection MSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort NURSINGTB.COM 30.Thenurseisawarethatforthe3-month-oldwhohasasurgerytimeof2:30PM,thestartorderforNPO shouldbenoearlierthan____________________. ANS: 8:30AM PeriodsofNPOshouldnotexceed4to6hoursforpediatricclientsbecausetheycanbecomedehydratedvery quickly. DIF:CognitiveLevel:ApplicationREF:Page520 TOP:NPOOrdersinInfantsKEY:NursingPro...