TEST BANK
ADVANCED PEDIATRIC ASSESSMENT
,Table of Contents
UNIT I: The Foundations of Child Health Assessment
1. Child Health Assessment: An Overview
2. Assessment of Child Development and Behavior
3. Communicating With Children and Families
4. Assessment of the Child's Family
5. Cultural Assessment of Children and Families
UNIT II: The Pediatric History and Physical Examination
6. Obtaining the Pediatric Health History
7. Assessing the Health and Safety of the Child's Environment
8. The Pediatric Physical Examination
9. The Health Supervision Visit: Wellness Examinations in Children
10. Assessment of Nutritional Status
11. Assessment of the Neonate
12. Assessment of the Integumentary System
13. Assessment of the Head, Neck, and Regional Lymphatics
14. Assessment of the Ears
15. Assessment of the Eyes
16. Assessment of the Face, Nose, and Oral Cavity
17. Assessment of the Thorax, Lungs, and Regional Lymphatics
18. Assessment of the Cardiovascular System
19. Assessment of the Abdomen and Regional Lymphatics
20. Assessment of the Reproductive and Genitourinary Systems
21. Assessment of the Musculoskeletal System
22. Assessment of the Neurologic System
UNIT III: Assessment of Child Mental Health and Welfare
23. Assessment of Mental Disorders in Children and Adolescents
24. Assessment of Child Abuse and Neglect
UNIT IV: Synthesizing the Components of the Pediatric Health Assessment
25. The Complete Pediatric History and Physical Examination: From Start to Finish
26. Diagnostic Reasoning and Formulating a Differential Diagnosis
,Chapter 1. Child Health Assessment: An
Overview
Multiple Choice
1. A Nurse Is Reviewing Changes In Healthcare Delivery And Funding For Pediatric Populations.
Which Current Trend In The Pediatric Setting Should The Nurse Expect To Find?
a. Increased Hospitalization Of Children
b. Decreased Number Of Uninsured Children
c. An Increase In Ambulatory Care
d. Decreased Use Of Managed
Care Answer: C
One Effect Of Managed Care Is That Pediatric Healthcare Delivery Has Shifted Dramatically
From The Acute Care Setting To The Ambulatory Setting. The Number Of Hospital Beds
Being Used Has Decreased As More Care Is Provided In Outpatient And Home Settings. The
Number Of Uninsured Children In The United States Continues To Grow. One Of The Biggest
Changes In Healthcare Has Been The Growth Of Managed Care.
Dif: Cognitive Level: Comprehension Ref: Dm 3
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
2. A Nurse Is Referring A Low-Income Family With Three Children Under The Age Of 5 Years
To A Program That Assists With Supplemental Food Supplies. Which Program Should The
Nurse Refer This Family To?
a. Medicaid
b. Medicare
c. Early And Periodic Screening, Diagnostic, And Treatment (Epsdt) Program
d. Women, Infants, And Children (Wic) Program
Answer: D
Wic Is A Federal Program That Provides Supplemental Food Supplies To Low-Income Women
Who Are Pregnant Or Breast-Feeding And To Their Children Until The Age Of 5 Years.
Medicaid And The Medicaid Early And Periodic Screening, Diagnostic, And Treatment (Epsdt)
Program Provides For Well-Child Examinations And Related Treatment Of Medical Problems.
Children In The Wic Program Are Often Referred For Immunizations, But That Is Not The
Primary Focus Of The Program. Public Law 99-457 Provides Financial Incentives To States To
Establish Comprehensive Early Intervention Services For Infants And Toddlers With, Or At
Risk For, Developmental Disabilities.
Medicare Is The Program For Senior
,Citizens. Dif: Cognitive Level: Application
Ref: Dm 7 Obj: Nursing Process Step:
Implementation Msc: Health Promotion
And Maintenance
3. In Most States, Adolescents Who Are Not Emancipated Minors Must Have Parental
Permission Before:
a. Treatment For Drug Abuse.
b. Treatment For Sexually Transmitted Diseases (Stds).
c. Obtaining Birth Control.
d. Surgery.
Answer: D
An Emancipated Minor Is A Minor Child Who Has The Legal Competence Of An Adult. Legal
Counsel May Be Consulted To Verify The Status Of The Emancipated Minor For Consent
Purposes. Most States Allow Minors To Obtain Treatment For Drug Or Alcohol Abuse And
Stds And Allow Access To Birth Control Without Parental Consent.
Dif: Cognitive Level: Application Ref: Dm 12
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
4. A Nurse Is Completing A Clinical Pathway For A Child Admitted To The Hospital With
Pneumonia. Which Characteristic Of A Clinical Pathway Is Correct?
a. Developed And Implemented By Nurses
b. Used Primarily In The Pediatric Setting
c. Specific Time Lines For Sequencing Interventions
d. One Of The Steps In The Nursing
Process Answer: C
Clinical Pathways Measure Outcomes Of Client Care And Are Developed By Multiple
Healthcare Professionals. Each Pathway Outlines Specific Time Lines For Sequencing
Interventions And Reflects Interdisciplinary Interventions. Clinical Pathways Are Used In
Multiple Settings And For Clients Throughout The Life Span. The Steps Of The Nursing
Process Are Assessment, Diagnosis, Planning, Implementation, And Evaluation.
Dif: Cognitive Level: Comprehension Ref: Dm 6
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
5. When Planning A Parenting Class, The Nurse Should Explain That The Leading Cause Of
Death In Children 1 To 4 Years Of Age In The United States Is:
a. Premature Birth.
,b. Congenital Anomalies.
c. Accidental Death.
d. Respiratory Tract
Illness. Answer: C
Accidents Are The Leading Cause Of Death In Children Ages 1 To 19 Years. Disorders Of
Short Gestation And Unspecified Low Birth Weight Make Up One Of The Leading Causes Of
Death In Neonates. One Of The Leading Causes Of Infant Death After The First Month Of Life
Is Congenital Anomalies. Respiratory Tract Illnesses Are A Major Cause Of Morbidity In
Children.
Dif: Cognitive Level: Application Ref: Dm 9
Obj: Nursing Process Step: Implementation
Msc: Safe And Effective Care Environment
6. Which Statement Is True Regarding The Quality Assurance Or Incident Report?
a. The Report Assures The Legal Department That There Is No Problem.
b. Reports Are A Permanent Part Of The Clients Chart.
c. The Nurses Notes Should Contain The Following: Incident Report Filed And
Copy Placed In Chart.
d. This Report Is A Form Of Documentation Of An Event That May Result In
Legal Action. Answer: D
An Incident Report Is A Warning To The Legal Department To Be Prepared For Potential
Legal Action; It Is Not A Part Of The Clients Chart Or Nurse Documentation.
Dif: Cognitive Level: Knowledge Ref: Dm 14 Obj:
Nursing Process Step: Implementation Msc: Safe
And Effective Care Environment
7. Which Client Situation Fails To Meet The First Requirement Of Informed Consent?
a. The Parent Does Not Understand The Physicians Explanations.
b. The Physician Gives The Parent Only A Partial List Of Possible Side
Effects And Complications.
c. No Parent Is Available And The Physician Asks The Adolescent To Sign The
Consent Form.
d. The Infants Teenage Mother Signs A Consent Form Because Her Parent Tells
Her To. Answer: C
,.
,The First Requirement Of Informed Consent Is That The Person Giving Consent Must Be
Competent. Minors Are Not Allowed To Give Consent. An Understanding Of Information, Full
Disclosure, And Voluntary Consent Are Requirements Of Informed Consent, But None Of
These Is The First Requirement.
Dif: Cognitive Level: Comprehension Ref: Dm 12
Obj: Nursing Process Step: Implementation
Msc: Safe And Effective Care Environment
8. A Nurse Assigned To A Child Does Not Know How To Perform A Treatment That Has Been
Prescribed For The Child. What Should The Nurses First Action Be?
a. Delay The Treatment Until Another Nurse Can Do It.
b. Make The Childs Parents Aware Of The Situation.
c. Inform The Nursing Supervisor Of The Problem.
d. Arrange To Have The Child Transferred To Another
Unit. Answer: C
If A Nurse Is Not Competent To Perform A Particular Nursing Task, The Nurse Must
Immediately Communicate This Fact To The Nursing Supervisor Or Physician. The Nurse
Could Endanger The Child By Delaying The Intervention Until Another Nurse Is Available.
Telling The Childs Parents Would Most Likely Increase Their Anxiety And Will Not Resolve
The Difficulty. Transfer To Another Unit Delays Needed Treatment And Would Create
Unnecessary Disruption For The Child And Family.
Dif: Cognitive Level: Application Ref: Dm 11 Obj:
Nursing Process Step: Implementation Msc: Safe
And Effective Care Environment
9. A Nurse Is Completing A Care Plan For A Child And Is Finishing The Assessment
Phase. Which Activity Is Not Part Of A Nursing Assessment?
.
a. Writing Nursing Diagnoses
b. Reviewing Diagnostic Reports
c. Collecting Data
,d. Setting Priorities
Answer: D
Setting Priorities Is A Part Of Planning. Writing Nursing Diagnoses, Reviewing Diagnostic
Reports, And Collecting Data Are Parts Of Assessment.
Dif: Cognitive Level: Comprehension Ref: Dm 19
Obj: Nursing Process Step: Planning Msc: Physiological Integrity
10. Which Patient Outcome Is Stated Correctly?
a. The Child Will Administer His Insulin Injection Before Breakfast On 10/31.
b. The Child Will Accept The Diagnosis Of Type 1 Diabetes Mellitus Before Discharge.
c. The Parents Will Understand How To Determine The Childs Daily Insulin Dosage.
d. The Nurse Will Monitor Blood Glucose Levels Before Meals And At
Bedtime. Answer: A
The Outcome Is Stated In Client Terms, With A Measurable Verb And A Time Frame For
Action. The Verb Accept Is Difficult To Measure. The Goal Of Accepting A Diagnosis Before
Hospital Discharge Is Unrealistic. Outcomes Should Be Stated In Client Terms. Nursing
Actions Are Determined After Outcomes Are Developed In The Implementation Phase Of The
Nursing Process.
Dif: Cognitive Level: Application Ref: Dm 20
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment Multiple
Response
.
1. A Nurse Is Reviewing The Nursing Care Plan For A Hospitalized Child. Which Statements Are
Collaborative Problems? Select All That Apply.
a. Risk For Injury
b. Potential Complication Of Seizure Disorder
c. Altered Nutrition: Less Than Body Requirements
d. Fluid Volume Deficit
e. Potential Complication Of Respiratory
Acidosis Answer: B, E
,In Addition To Nursing Diagnoses, Which Describe Problems That Respond To Independent
Nursing Functions, Nurses Must Also Deal With Problems That Are Beyond The Scope Of
Independent Nursing Practice. These Are Sometimes Termed Collaborative Problemsphysiological
Complications That
Usually Occur In Association With A Specific Pathological Condition Or Treatment. The
Potential Complications Of Seizure Disorder And Respiratory Acidosis Are Physiological
Complications That Will Require Physician Collaboration To Treat. Risk For Injury, Altered
Nutrition, And Fluid Volume Deficit Will Respond To Independent Nursing Functions.
Dif: Cognitive Level: Application Ref: Dm 20
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
2. Which Nursing Activities Do Not Meet The Standard Of Care? Select All That Apply.
a. Failure To Notify A Physician About A Childs Worsening Condition
b. Calling The Supervisor About Staffing Concerns
c. Delegating Assessment Of A New Admit To The Unlicensed Assistive
Personnel (Uap)
d. Asking The Unlicensed Assistive Personnel (Uap) To Take Vital Signs
e. Documenting That A Physician Was Unavailable And The Nursing
Supervisor Was Notified
Answer: A, C
.
A Nurse Who Fails To Notify A Physician About A Childs Worsening Condition And
Delegating The Assessment Of A New Admit To A Uap Do Not Meet The Standard Of
Care. Calling The Supervisor About Staffing Concerns, Asking The Uap To Take Vital
Signs, And Documenting That A Physician Could Not Be Reached And The Nursing
Supervisor Was Notified All Meet The Standard Of Care.
Chapter 2. Assessment Of Child Development And
Behavior Multiple Choice
1. The Nurse Is Performing An Abdominal Assessment On A Child. When Percussing
Over The Stomach, The Nurse Should Hear Which Sound?
a. Tympany
, b. Resonance
c. Flatness
d. Dullness
Answer: A
Tympany Is A High-Pitched, Loud-Intensity Sound Heard Over Air-Filled Body Parts Such As
The Stomach And Bowel. Resonance Is A Low-Pitched, Low-Intensity Sound Elicited Over
Hollow Organs Such As The Lungs. Flatness Is A High-Pitched, Soft-Intensity Sound Elicited
By Percussing Over Solid Masses Such As Bone Or Muscle. Dullness Is A Medium-Pitched,
Medium-Intensity Sound Elicited When Percussing Over High-Density Structures Such As The
Liver.
Dif: Cognitive Level: Application Ref: Dm 170
Obj: Nursing Process Step: Assessment Msc: Health Promotion And Maintenance
2. A Nurse Is Preparing To Begin An Assessment On A Newly Admitted Child. The Nurse
Should Be Aware That The Single Most Important Component Of A Pediatric Physical
Examination Is:
a. Assessment Of Heart And Lungs.
b. Measurement Of Height And Weight.
.
c. Documentation Of Parental Concerns.
d. Obtaining An Accurate
History. Answer: D
An Accurate History Is Most Helpful In Identifying Problems And Potential Problems. Heart
And Lung Assessment And Documentation Of Parental Concerns Are Not As Important As An
Accurate History. A Single Measurement Of Height And Weight Is Not As Significant As
Determining Growth Over Time. The Childs Growth Pattern Can Be Elicited From The
History.
Dif: Cognitive Level: Comprehension Ref: Dm 171
Obj: Nursing Process Step: Assessment Msc: Health Promotion And Maintenance
3. In Which Section Of The Health History Should The Nurse Record That The Parent Brought
The Infant To The Clinic Today Because Of Frequent Diarrhea?
a. Review Of Systems
ADVANCED PEDIATRIC ASSESSMENT
,Table of Contents
UNIT I: The Foundations of Child Health Assessment
1. Child Health Assessment: An Overview
2. Assessment of Child Development and Behavior
3. Communicating With Children and Families
4. Assessment of the Child's Family
5. Cultural Assessment of Children and Families
UNIT II: The Pediatric History and Physical Examination
6. Obtaining the Pediatric Health History
7. Assessing the Health and Safety of the Child's Environment
8. The Pediatric Physical Examination
9. The Health Supervision Visit: Wellness Examinations in Children
10. Assessment of Nutritional Status
11. Assessment of the Neonate
12. Assessment of the Integumentary System
13. Assessment of the Head, Neck, and Regional Lymphatics
14. Assessment of the Ears
15. Assessment of the Eyes
16. Assessment of the Face, Nose, and Oral Cavity
17. Assessment of the Thorax, Lungs, and Regional Lymphatics
18. Assessment of the Cardiovascular System
19. Assessment of the Abdomen and Regional Lymphatics
20. Assessment of the Reproductive and Genitourinary Systems
21. Assessment of the Musculoskeletal System
22. Assessment of the Neurologic System
UNIT III: Assessment of Child Mental Health and Welfare
23. Assessment of Mental Disorders in Children and Adolescents
24. Assessment of Child Abuse and Neglect
UNIT IV: Synthesizing the Components of the Pediatric Health Assessment
25. The Complete Pediatric History and Physical Examination: From Start to Finish
26. Diagnostic Reasoning and Formulating a Differential Diagnosis
,Chapter 1. Child Health Assessment: An
Overview
Multiple Choice
1. A Nurse Is Reviewing Changes In Healthcare Delivery And Funding For Pediatric Populations.
Which Current Trend In The Pediatric Setting Should The Nurse Expect To Find?
a. Increased Hospitalization Of Children
b. Decreased Number Of Uninsured Children
c. An Increase In Ambulatory Care
d. Decreased Use Of Managed
Care Answer: C
One Effect Of Managed Care Is That Pediatric Healthcare Delivery Has Shifted Dramatically
From The Acute Care Setting To The Ambulatory Setting. The Number Of Hospital Beds
Being Used Has Decreased As More Care Is Provided In Outpatient And Home Settings. The
Number Of Uninsured Children In The United States Continues To Grow. One Of The Biggest
Changes In Healthcare Has Been The Growth Of Managed Care.
Dif: Cognitive Level: Comprehension Ref: Dm 3
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
2. A Nurse Is Referring A Low-Income Family With Three Children Under The Age Of 5 Years
To A Program That Assists With Supplemental Food Supplies. Which Program Should The
Nurse Refer This Family To?
a. Medicaid
b. Medicare
c. Early And Periodic Screening, Diagnostic, And Treatment (Epsdt) Program
d. Women, Infants, And Children (Wic) Program
Answer: D
Wic Is A Federal Program That Provides Supplemental Food Supplies To Low-Income Women
Who Are Pregnant Or Breast-Feeding And To Their Children Until The Age Of 5 Years.
Medicaid And The Medicaid Early And Periodic Screening, Diagnostic, And Treatment (Epsdt)
Program Provides For Well-Child Examinations And Related Treatment Of Medical Problems.
Children In The Wic Program Are Often Referred For Immunizations, But That Is Not The
Primary Focus Of The Program. Public Law 99-457 Provides Financial Incentives To States To
Establish Comprehensive Early Intervention Services For Infants And Toddlers With, Or At
Risk For, Developmental Disabilities.
Medicare Is The Program For Senior
,Citizens. Dif: Cognitive Level: Application
Ref: Dm 7 Obj: Nursing Process Step:
Implementation Msc: Health Promotion
And Maintenance
3. In Most States, Adolescents Who Are Not Emancipated Minors Must Have Parental
Permission Before:
a. Treatment For Drug Abuse.
b. Treatment For Sexually Transmitted Diseases (Stds).
c. Obtaining Birth Control.
d. Surgery.
Answer: D
An Emancipated Minor Is A Minor Child Who Has The Legal Competence Of An Adult. Legal
Counsel May Be Consulted To Verify The Status Of The Emancipated Minor For Consent
Purposes. Most States Allow Minors To Obtain Treatment For Drug Or Alcohol Abuse And
Stds And Allow Access To Birth Control Without Parental Consent.
Dif: Cognitive Level: Application Ref: Dm 12
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
4. A Nurse Is Completing A Clinical Pathway For A Child Admitted To The Hospital With
Pneumonia. Which Characteristic Of A Clinical Pathway Is Correct?
a. Developed And Implemented By Nurses
b. Used Primarily In The Pediatric Setting
c. Specific Time Lines For Sequencing Interventions
d. One Of The Steps In The Nursing
Process Answer: C
Clinical Pathways Measure Outcomes Of Client Care And Are Developed By Multiple
Healthcare Professionals. Each Pathway Outlines Specific Time Lines For Sequencing
Interventions And Reflects Interdisciplinary Interventions. Clinical Pathways Are Used In
Multiple Settings And For Clients Throughout The Life Span. The Steps Of The Nursing
Process Are Assessment, Diagnosis, Planning, Implementation, And Evaluation.
Dif: Cognitive Level: Comprehension Ref: Dm 6
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
5. When Planning A Parenting Class, The Nurse Should Explain That The Leading Cause Of
Death In Children 1 To 4 Years Of Age In The United States Is:
a. Premature Birth.
,b. Congenital Anomalies.
c. Accidental Death.
d. Respiratory Tract
Illness. Answer: C
Accidents Are The Leading Cause Of Death In Children Ages 1 To 19 Years. Disorders Of
Short Gestation And Unspecified Low Birth Weight Make Up One Of The Leading Causes Of
Death In Neonates. One Of The Leading Causes Of Infant Death After The First Month Of Life
Is Congenital Anomalies. Respiratory Tract Illnesses Are A Major Cause Of Morbidity In
Children.
Dif: Cognitive Level: Application Ref: Dm 9
Obj: Nursing Process Step: Implementation
Msc: Safe And Effective Care Environment
6. Which Statement Is True Regarding The Quality Assurance Or Incident Report?
a. The Report Assures The Legal Department That There Is No Problem.
b. Reports Are A Permanent Part Of The Clients Chart.
c. The Nurses Notes Should Contain The Following: Incident Report Filed And
Copy Placed In Chart.
d. This Report Is A Form Of Documentation Of An Event That May Result In
Legal Action. Answer: D
An Incident Report Is A Warning To The Legal Department To Be Prepared For Potential
Legal Action; It Is Not A Part Of The Clients Chart Or Nurse Documentation.
Dif: Cognitive Level: Knowledge Ref: Dm 14 Obj:
Nursing Process Step: Implementation Msc: Safe
And Effective Care Environment
7. Which Client Situation Fails To Meet The First Requirement Of Informed Consent?
a. The Parent Does Not Understand The Physicians Explanations.
b. The Physician Gives The Parent Only A Partial List Of Possible Side
Effects And Complications.
c. No Parent Is Available And The Physician Asks The Adolescent To Sign The
Consent Form.
d. The Infants Teenage Mother Signs A Consent Form Because Her Parent Tells
Her To. Answer: C
,.
,The First Requirement Of Informed Consent Is That The Person Giving Consent Must Be
Competent. Minors Are Not Allowed To Give Consent. An Understanding Of Information, Full
Disclosure, And Voluntary Consent Are Requirements Of Informed Consent, But None Of
These Is The First Requirement.
Dif: Cognitive Level: Comprehension Ref: Dm 12
Obj: Nursing Process Step: Implementation
Msc: Safe And Effective Care Environment
8. A Nurse Assigned To A Child Does Not Know How To Perform A Treatment That Has Been
Prescribed For The Child. What Should The Nurses First Action Be?
a. Delay The Treatment Until Another Nurse Can Do It.
b. Make The Childs Parents Aware Of The Situation.
c. Inform The Nursing Supervisor Of The Problem.
d. Arrange To Have The Child Transferred To Another
Unit. Answer: C
If A Nurse Is Not Competent To Perform A Particular Nursing Task, The Nurse Must
Immediately Communicate This Fact To The Nursing Supervisor Or Physician. The Nurse
Could Endanger The Child By Delaying The Intervention Until Another Nurse Is Available.
Telling The Childs Parents Would Most Likely Increase Their Anxiety And Will Not Resolve
The Difficulty. Transfer To Another Unit Delays Needed Treatment And Would Create
Unnecessary Disruption For The Child And Family.
Dif: Cognitive Level: Application Ref: Dm 11 Obj:
Nursing Process Step: Implementation Msc: Safe
And Effective Care Environment
9. A Nurse Is Completing A Care Plan For A Child And Is Finishing The Assessment
Phase. Which Activity Is Not Part Of A Nursing Assessment?
.
a. Writing Nursing Diagnoses
b. Reviewing Diagnostic Reports
c. Collecting Data
,d. Setting Priorities
Answer: D
Setting Priorities Is A Part Of Planning. Writing Nursing Diagnoses, Reviewing Diagnostic
Reports, And Collecting Data Are Parts Of Assessment.
Dif: Cognitive Level: Comprehension Ref: Dm 19
Obj: Nursing Process Step: Planning Msc: Physiological Integrity
10. Which Patient Outcome Is Stated Correctly?
a. The Child Will Administer His Insulin Injection Before Breakfast On 10/31.
b. The Child Will Accept The Diagnosis Of Type 1 Diabetes Mellitus Before Discharge.
c. The Parents Will Understand How To Determine The Childs Daily Insulin Dosage.
d. The Nurse Will Monitor Blood Glucose Levels Before Meals And At
Bedtime. Answer: A
The Outcome Is Stated In Client Terms, With A Measurable Verb And A Time Frame For
Action. The Verb Accept Is Difficult To Measure. The Goal Of Accepting A Diagnosis Before
Hospital Discharge Is Unrealistic. Outcomes Should Be Stated In Client Terms. Nursing
Actions Are Determined After Outcomes Are Developed In The Implementation Phase Of The
Nursing Process.
Dif: Cognitive Level: Application Ref: Dm 20
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment Multiple
Response
.
1. A Nurse Is Reviewing The Nursing Care Plan For A Hospitalized Child. Which Statements Are
Collaborative Problems? Select All That Apply.
a. Risk For Injury
b. Potential Complication Of Seizure Disorder
c. Altered Nutrition: Less Than Body Requirements
d. Fluid Volume Deficit
e. Potential Complication Of Respiratory
Acidosis Answer: B, E
,In Addition To Nursing Diagnoses, Which Describe Problems That Respond To Independent
Nursing Functions, Nurses Must Also Deal With Problems That Are Beyond The Scope Of
Independent Nursing Practice. These Are Sometimes Termed Collaborative Problemsphysiological
Complications That
Usually Occur In Association With A Specific Pathological Condition Or Treatment. The
Potential Complications Of Seizure Disorder And Respiratory Acidosis Are Physiological
Complications That Will Require Physician Collaboration To Treat. Risk For Injury, Altered
Nutrition, And Fluid Volume Deficit Will Respond To Independent Nursing Functions.
Dif: Cognitive Level: Application Ref: Dm 20
Obj: Nursing Process Step: Planning Msc: Safe And Effective Care Environment
2. Which Nursing Activities Do Not Meet The Standard Of Care? Select All That Apply.
a. Failure To Notify A Physician About A Childs Worsening Condition
b. Calling The Supervisor About Staffing Concerns
c. Delegating Assessment Of A New Admit To The Unlicensed Assistive
Personnel (Uap)
d. Asking The Unlicensed Assistive Personnel (Uap) To Take Vital Signs
e. Documenting That A Physician Was Unavailable And The Nursing
Supervisor Was Notified
Answer: A, C
.
A Nurse Who Fails To Notify A Physician About A Childs Worsening Condition And
Delegating The Assessment Of A New Admit To A Uap Do Not Meet The Standard Of
Care. Calling The Supervisor About Staffing Concerns, Asking The Uap To Take Vital
Signs, And Documenting That A Physician Could Not Be Reached And The Nursing
Supervisor Was Notified All Meet The Standard Of Care.
Chapter 2. Assessment Of Child Development And
Behavior Multiple Choice
1. The Nurse Is Performing An Abdominal Assessment On A Child. When Percussing
Over The Stomach, The Nurse Should Hear Which Sound?
a. Tympany
, b. Resonance
c. Flatness
d. Dullness
Answer: A
Tympany Is A High-Pitched, Loud-Intensity Sound Heard Over Air-Filled Body Parts Such As
The Stomach And Bowel. Resonance Is A Low-Pitched, Low-Intensity Sound Elicited Over
Hollow Organs Such As The Lungs. Flatness Is A High-Pitched, Soft-Intensity Sound Elicited
By Percussing Over Solid Masses Such As Bone Or Muscle. Dullness Is A Medium-Pitched,
Medium-Intensity Sound Elicited When Percussing Over High-Density Structures Such As The
Liver.
Dif: Cognitive Level: Application Ref: Dm 170
Obj: Nursing Process Step: Assessment Msc: Health Promotion And Maintenance
2. A Nurse Is Preparing To Begin An Assessment On A Newly Admitted Child. The Nurse
Should Be Aware That The Single Most Important Component Of A Pediatric Physical
Examination Is:
a. Assessment Of Heart And Lungs.
b. Measurement Of Height And Weight.
.
c. Documentation Of Parental Concerns.
d. Obtaining An Accurate
History. Answer: D
An Accurate History Is Most Helpful In Identifying Problems And Potential Problems. Heart
And Lung Assessment And Documentation Of Parental Concerns Are Not As Important As An
Accurate History. A Single Measurement Of Height And Weight Is Not As Significant As
Determining Growth Over Time. The Childs Growth Pattern Can Be Elicited From The
History.
Dif: Cognitive Level: Comprehension Ref: Dm 171
Obj: Nursing Process Step: Assessment Msc: Health Promotion And Maintenance
3. In Which Section Of The Health History Should The Nurse Record That The Parent Brought
The Infant To The Clinic Today Because Of Frequent Diarrhea?
a. Review Of Systems
