Ricci Chapter 42 - Test Bank - 4th Edition || 100% Error-free
Solutions.
1. The nurse is teaching the mother of a 5-year-old boy with a history of
impaction how to administer enemas at home. Which response from the mother
indicates a need for further teaching?
A) "I should position him on his abdomen with knees bent."
B) "He will require 250 to 500 mL of enema solution."
C) "I should wash my hands and then wear gloves."
D) "He should retain the solution for 5 to 10 minutes." Correct Ans: A
Feedback:
A 5-year-old child should lie on his left side with his right leg flexed toward the
chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of
solution, washing hands and wearing gloves, and retaining the solution for 5 to 10
minutes are appropriate responses.
2. The nurse is taking a health history of an 11-year-old girl with recurrent
abdominal pain. Which response would lead the nurse to suspect irritable bowel
syndrome?
A) "I always feel better after I have a bowel movement."
B) "I don't take any medicine right now."
C) "The pain comes and goes."
D) "The pain doesn't wake me up in the middle of the night." Correct Ans: A
Feedback:
In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of
medications and pain that comes and goes or wakes the person up in the middle of
the night are all relevant findings pertinent to recurrent abdominal pain.
3. The nurse is caring for a 3-year-old girl with short bowel syndrome as a
result of trauma to the small intestine. The girl's mother is extremely anxious and
tells the nurse she is afraid she will never learn how to care for her daughter at
home. How should the nurse respond?
A) "I will help you become an expert on your daughter's care."
B) "You must learn how to care for your daughter at home."
C) "You really need the support of your husband."
D) "There is a lot to learn and you need a positive attitude." Correct Ans: A
Feedback:
The nurse needs to empower families to become the experts on their children's
needs and conditions via education and participation in care. The most positive
approach in this case is to let the mother know the nurse will support her and help
her become an expert on her daughter's care. Telling the mother that she must
learn how to care for her daughter or that she must have a positive attitude is not
helpful. Telling her that she needs the support of her husband is irrelevant and
unhelpful.
4. The nurse is conducting a physical examination of a child with suspected
, Crohn disease. Which finding would be the most suspicious of Crohn disease?
A) Normal growth patterns
B) Perianal skin tags or fissures
C) Poor growth patterns
D) Abdominal tenderness Correct Ans: B
Feedback:
Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor
growth patterns and abdominal tenderness are common to Crohn disease but are
also seen with many other conditions. Normal growth patterns would not point to
Crohn disease because of problems with absorbing nutrients.
5. The nurse is caring for an infant with a temporary ileostomy. As part of the
plan of care, the nurse monitors for skin breakdown around the stoma. If redness
occurs, what would be most appropriate to promote healing and prevent further
skin breakdown?
A) Clean the area well with a scented diaper wipe.
B) Apply a barrier/healing cream or paste on the skin.
C) Use a barrier wafer to attach the appliance.
D) Sanitize the area with an alcohol wipe after each diaper change. Correct Ans: B
Feedback:
The nurse should use a barrier/healing cream or paste on the skin around the
stoma to promote healing and prevent further skin breakdown. Diaper wipes that
contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin
breakdown. The barrier wafer would be helpful but does not address the skin
breakdown.
6. The nurse is caring for a 4-year-old boy who has undergone an
appendectomy. The child is unwilling to use the incentive spirometer. Which
approach would be most appropriate to elicit the child's cooperation?
A) "Can you cough for me please?"
B) "You must blow in this or you might get pneumonia."
C) "If you don't try, I will have to get the healthcare provider."
D) "Can you blow this cotton ball across the tray?" Correct Ans: D
Feedback:
Children are more likely to cooperate with interventions if play is involved.
Encourage deep breathing by playing games. Asking the boy to cough is less likely
to engage him. Telling the child he might get pneumonia is not age appropriate and
is unhelpful. Threatening to call the healthcare provider is unhelpful and
inappropriate. Remember, however, that the incentive spirometer works on the
principle of the amount of air inhaled, not exhaled. Having the child take a deep
breath prior to blowing the cotton ball is a beginning step.
7. A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper
gastrointestinal (GI) series. Before providing instructions, what would be the
priority?
A) Screening the girl for pregnancy
Solutions.
1. The nurse is teaching the mother of a 5-year-old boy with a history of
impaction how to administer enemas at home. Which response from the mother
indicates a need for further teaching?
A) "I should position him on his abdomen with knees bent."
B) "He will require 250 to 500 mL of enema solution."
C) "I should wash my hands and then wear gloves."
D) "He should retain the solution for 5 to 10 minutes." Correct Ans: A
Feedback:
A 5-year-old child should lie on his left side with his right leg flexed toward the
chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of
solution, washing hands and wearing gloves, and retaining the solution for 5 to 10
minutes are appropriate responses.
2. The nurse is taking a health history of an 11-year-old girl with recurrent
abdominal pain. Which response would lead the nurse to suspect irritable bowel
syndrome?
A) "I always feel better after I have a bowel movement."
B) "I don't take any medicine right now."
C) "The pain comes and goes."
D) "The pain doesn't wake me up in the middle of the night." Correct Ans: A
Feedback:
In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of
medications and pain that comes and goes or wakes the person up in the middle of
the night are all relevant findings pertinent to recurrent abdominal pain.
3. The nurse is caring for a 3-year-old girl with short bowel syndrome as a
result of trauma to the small intestine. The girl's mother is extremely anxious and
tells the nurse she is afraid she will never learn how to care for her daughter at
home. How should the nurse respond?
A) "I will help you become an expert on your daughter's care."
B) "You must learn how to care for your daughter at home."
C) "You really need the support of your husband."
D) "There is a lot to learn and you need a positive attitude." Correct Ans: A
Feedback:
The nurse needs to empower families to become the experts on their children's
needs and conditions via education and participation in care. The most positive
approach in this case is to let the mother know the nurse will support her and help
her become an expert on her daughter's care. Telling the mother that she must
learn how to care for her daughter or that she must have a positive attitude is not
helpful. Telling her that she needs the support of her husband is irrelevant and
unhelpful.
4. The nurse is conducting a physical examination of a child with suspected
, Crohn disease. Which finding would be the most suspicious of Crohn disease?
A) Normal growth patterns
B) Perianal skin tags or fissures
C) Poor growth patterns
D) Abdominal tenderness Correct Ans: B
Feedback:
Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor
growth patterns and abdominal tenderness are common to Crohn disease but are
also seen with many other conditions. Normal growth patterns would not point to
Crohn disease because of problems with absorbing nutrients.
5. The nurse is caring for an infant with a temporary ileostomy. As part of the
plan of care, the nurse monitors for skin breakdown around the stoma. If redness
occurs, what would be most appropriate to promote healing and prevent further
skin breakdown?
A) Clean the area well with a scented diaper wipe.
B) Apply a barrier/healing cream or paste on the skin.
C) Use a barrier wafer to attach the appliance.
D) Sanitize the area with an alcohol wipe after each diaper change. Correct Ans: B
Feedback:
The nurse should use a barrier/healing cream or paste on the skin around the
stoma to promote healing and prevent further skin breakdown. Diaper wipes that
contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin
breakdown. The barrier wafer would be helpful but does not address the skin
breakdown.
6. The nurse is caring for a 4-year-old boy who has undergone an
appendectomy. The child is unwilling to use the incentive spirometer. Which
approach would be most appropriate to elicit the child's cooperation?
A) "Can you cough for me please?"
B) "You must blow in this or you might get pneumonia."
C) "If you don't try, I will have to get the healthcare provider."
D) "Can you blow this cotton ball across the tray?" Correct Ans: D
Feedback:
Children are more likely to cooperate with interventions if play is involved.
Encourage deep breathing by playing games. Asking the boy to cough is less likely
to engage him. Telling the child he might get pneumonia is not age appropriate and
is unhelpful. Threatening to call the healthcare provider is unhelpful and
inappropriate. Remember, however, that the incentive spirometer works on the
principle of the amount of air inhaled, not exhaled. Having the child take a deep
breath prior to blowing the cotton ball is a beginning step.
7. A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper
gastrointestinal (GI) series. Before providing instructions, what would be the
priority?
A) Screening the girl for pregnancy
