Maternal-Child McKinney Ch 37:
Principles and Procedures for Nursing
Care of Children Practice Questions
and Correct Answers.
1. What is the most appropriate statement for the nurse to make to a 5-year-old child who is
undergoing a venipuncture?
a. "You must hold still or I'll have someone hold you down. This is not going to
hurt."
b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will
be over fast and hurt less."
c. "Be a big boy and hold still. This will be over in just a second."
d. "I'm sending your mother out so she won't be scared. You are big, so hold still
and this will be over soon." - Answer ANS: B
The nurse can help minimize the pain and stress of the venipuncture by having someone help
the child maintain control during the procedure. Threatening the child with having someone
hold him or her down is likely to produce less cooperation and frighten the child. Telling a child
to be a "big boy" does not acknowledge the child's developmental stage. Parents should be
allowed to stay during procedures when possible.
2. Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of
immunosuppression?
a. Spiritual distress
b. Social isolation
c. Deficient diversional activity
d. Sleep deprivation - Answer ANS: C
Children in isolation need extra attention to avoid boredom. A 5-year-old child is not
developmentally advanced enough to feel spiritual distress. The main social system for a 5-year-
old child is the family, who should be allowed liberal visitation. Sleep deprivation may occur
during hospitalization but is not specific to isolation.
3. What should the nurse consider when having consent forms signed for surgery and
procedures on children?
a. Only a parent or legal guardian can give consent.
, The informed consent must include the nature of the procedure, benefits and risks, and
alternatives to the procedure. In special circumstances, such as emancipated minors, the
consent can be given by someone younger than 18 years without the parent or legal guardian. A
mental age of 7 years is too young for consent to be informed.
4. The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures.
Guidelines for preparing this preschooler should include
a. planning for a short teaching session of about 30 minutes.
b. telling the child that procedures are never a form of punishment.
c. keeping equipment out of the child's view.
d. using correct scientific and medical terminology in explanations. - Answer ANS: B
Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly
that procedures are never a form of punishment. Teaching sessions for this age-group should be
much shorter in length. Demonstrate the use of equipment, and allow the child to play with
miniature or actual equipment. Explain the procedure in simple terms and how it affects the
child.
5. Which nursing action is most appropriate when treating a child who has a fever of 102.5° F
(39.1° C)?
a. Restrict fluid intake.
b. Administer an aspirin.
c. Administer acetaminophen.
d. Bathe the child in tepid water. - Answer ANS: C
Treatment of a fever can include administration of an antipyretic such as acetaminophen.
Dehydration can occur from insensible water loss. Offer the child fluids frequently and evaluate
the need for IV therapy. Aspirin is avoided because of the potential association with Reye
syndrome. A sponge or tub bath with tepid water to reduce fever can cause shivering and
ultimately increase the child's temperature.
6. A parent asked, "When should I start dental care for my child?" What response by the nurse is
best?
a. "The recommendation is for children to have a dental examination no later than
2.5 years."
b. "Children should see a dentist at least one time before kindergarten."
c. "The recommendation is for children to have a dental examination before first
grade."
Principles and Procedures for Nursing
Care of Children Practice Questions
and Correct Answers.
1. What is the most appropriate statement for the nurse to make to a 5-year-old child who is
undergoing a venipuncture?
a. "You must hold still or I'll have someone hold you down. This is not going to
hurt."
b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will
be over fast and hurt less."
c. "Be a big boy and hold still. This will be over in just a second."
d. "I'm sending your mother out so she won't be scared. You are big, so hold still
and this will be over soon." - Answer ANS: B
The nurse can help minimize the pain and stress of the venipuncture by having someone help
the child maintain control during the procedure. Threatening the child with having someone
hold him or her down is likely to produce less cooperation and frighten the child. Telling a child
to be a "big boy" does not acknowledge the child's developmental stage. Parents should be
allowed to stay during procedures when possible.
2. Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of
immunosuppression?
a. Spiritual distress
b. Social isolation
c. Deficient diversional activity
d. Sleep deprivation - Answer ANS: C
Children in isolation need extra attention to avoid boredom. A 5-year-old child is not
developmentally advanced enough to feel spiritual distress. The main social system for a 5-year-
old child is the family, who should be allowed liberal visitation. Sleep deprivation may occur
during hospitalization but is not specific to isolation.
3. What should the nurse consider when having consent forms signed for surgery and
procedures on children?
a. Only a parent or legal guardian can give consent.
, The informed consent must include the nature of the procedure, benefits and risks, and
alternatives to the procedure. In special circumstances, such as emancipated minors, the
consent can be given by someone younger than 18 years without the parent or legal guardian. A
mental age of 7 years is too young for consent to be informed.
4. The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures.
Guidelines for preparing this preschooler should include
a. planning for a short teaching session of about 30 minutes.
b. telling the child that procedures are never a form of punishment.
c. keeping equipment out of the child's view.
d. using correct scientific and medical terminology in explanations. - Answer ANS: B
Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly
that procedures are never a form of punishment. Teaching sessions for this age-group should be
much shorter in length. Demonstrate the use of equipment, and allow the child to play with
miniature or actual equipment. Explain the procedure in simple terms and how it affects the
child.
5. Which nursing action is most appropriate when treating a child who has a fever of 102.5° F
(39.1° C)?
a. Restrict fluid intake.
b. Administer an aspirin.
c. Administer acetaminophen.
d. Bathe the child in tepid water. - Answer ANS: C
Treatment of a fever can include administration of an antipyretic such as acetaminophen.
Dehydration can occur from insensible water loss. Offer the child fluids frequently and evaluate
the need for IV therapy. Aspirin is avoided because of the potential association with Reye
syndrome. A sponge or tub bath with tepid water to reduce fever can cause shivering and
ultimately increase the child's temperature.
6. A parent asked, "When should I start dental care for my child?" What response by the nurse is
best?
a. "The recommendation is for children to have a dental examination no later than
2.5 years."
b. "Children should see a dentist at least one time before kindergarten."
c. "The recommendation is for children to have a dental examination before first
grade."
