Test Bank for Wong’s Essentials of Pediatric Nursing,
11th Edition, Marilyn Hockenberry, Cheryl Rodgers Chapters
1 - 31
,
,Chapter 01: Perspectives of Pediatric Nursing
Hockenberry: Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A nurse is planning a teaching session for parents of preschool children. Which statement ex-
plains why the nurse should include information about morbidity and mortality?
a. Life span statistics are included in the data.
b. It explains effectiveness of treatment.
c. Cost-effective treatment is detailed for the
general population.
d. High-risk age groups for certain disorders or
hazards are identified.
ANSWER: D
Analysis of morbidity and mortality data provides the parents with information about which
groups of individuals are at risk for which health problems. Life span statistics is a part of the
mortality data. Treatment modalities and cost are not included in morbidity and mortality data.
DIF: Cognitive Level: Apply REF: p. 11
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A clinic nurse is planning a teaching session about childhood obesity prevention for parents of
school-age children. The nurse should include which associated risk of obesity in the teaching
plan?
a. Type I diabetes
b. Respiratory disease
c. Celiac disease
d. Type II diabetes
ANSWER: D
Childhood obesity has been associated with the rise of type II diabetes in children. Type I dia-
betes is not associated with obesity and has a genetic component. Respiratory disease is not asso-
ciated with obesity, and celiac disease is the inability to metabolize gluten in foods and is not as-
sociated with obesity.
DIF: Cognitive Level: Apply REF: p. 2
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is the leading cause of death in infants younger than 1 year?
a. Congenital anomalies
b. Sudden infant death syndrome
c. Respiratory distress syndrome
d. Bacterial sepsis of the newborn
ANSWER: A
, Congenital anomalies account for 20.1% of deaths in infants younger than 1 year. Sudden infant
death syndrome accounts for 8.2% of deaths in this age group. Respiratory distress syndrome ac-
counts for 3.4% of deaths in this age group. Infections specific to the perinatal period account for
2.7% of deaths in this age group.
DIF: Cognitive Level: Remember REF: p. 6
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which leading cause of death topic should the nurse emphasize to a group of African-American
boys ranging in age from 15 to 19 years?
a. Suicide
b. Cancer
c. Firearm homicide
d. Occupational injuries
ANSWER: C
Firearm homicide is the second overall cause of death in this age group and the leading cause of
death in African-American males. Suicide is the third-leading cause of death in this population.
Cancer, although a major health problem, is the fourth-leading cause of death in this age group.
Occupational injuries do not contribute to a significant death rate for this age group.
DIF: Cognitive Level: Understand REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which is the major cause of death for children older than 1 year?
a. Cancer
b. Heart disease
c. Unintentional injuries
d. Congenital anomalies
ANSWER: C
Unintentional injuries (accidents) are the leading cause of death after age 1 year through adoles-
cence. Congenital anomalies are the leading cause of death in those younger than 1 year. Cancer
ranks either second or fourth, depending on the age group, and heart disease ranks fifth in the
majority of the age groups.
DIF: Cognitive Level: Remember REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which is the leading cause of death from unintentional injuries for females ranging in age from 1
to 14?
a. Mechanical suffocation
b. Drowning
c. Motor vehicle–related fatalities
d. Fire- and burn-related fatalities
, ANSWER: C
Motor vehicle–related fatalities are the leading cause of death for females ranging in age from 1
to 14, either as passengers or as pedestrians. Mechanical suffocation is fourth or fifth, depending
on the age. Drowning is the second- or third-leading cause of death, depending on the age. Fire-
and burn-related fatalities are the second-leading cause of death.
DIF: Cognitive Level: Remember REF: p. 3
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which factor most impacts the type of injury a child is susceptible to, according to the child’s
age?
a. Physical health of the child
b. Developmental level of the child
c. Educational level of the child
d. Number of responsible adults in the home
ANSWER: B
The child’s developmental stage determines the type of injury that is likely to occur. The child’s
physical health may facilitate the child’s recovery from an injury but does not impact the type of
injury. Educational level is related to developmental level, but it is not as important as the child’s
developmental level in determining the type of injury. The number of responsible adults in the
home may affect the number of unintentional injuries, but the type of injury is related to the
child’s developmental stage.
DIF: Cognitive Level: Understand REF: p. 3
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which is now referred to as the “new morbidity”?
a. Limitations in the major activities of daily
living
b. Unintentional injuries that cause chronic
health problems
c. Discoveries of new therapies to treat health
problems
d. Behavioral, social, and educational problem s
that alter health
ANSWER: D
The new morbidity reflects the behavioral, social, and educational problems that interfere with
the child’s social and academic development. It is currently estimated that the incidence of these
issues is from 5% to 30%. Limitations in major activities of daily living and unintentional in-
juries that result in chronic health problems are included in morbidity data. Discovery of new
therapies would be reflected in changes in morbidity data over time.
DIF: Cognitive Level: Remember REF: p. 2
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
, 9. A nurse on a pediatric unit is practicing family-centered care. Which is most descriptive of the
care the nurse is delivering?
a. Taking over total care of the child to reduce
stress on the family
b. Encouraging family dependence on health
care systems
c. Recognizing that the family is the constant i n
a child’s life
d. Excluding families from the decision-making
process
ANSWER: C
The three key components of family-centered care are respect, collaboration, and support. Fam-
ily-centered care recognizes the family as the constant in the child’s life. Taking over total care
does not include the family in the process and may increase stress instead of reducing stress. The
family should be enabled and empowered to work with the health care system. The family is ex-
pected to be part of the decision-making process.
DIF: Cognitive Level: Remember REF: p. 7
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. The nurse is preparing an in-service education to staff about atraumatic care for pediatric pa-
tients. Which intervention should the nurse include?
a. Prepare the child for separation from parent s
during hospitalization by reviewing a video.
b. Prepare the child before any unfamiliar trea t
ment or procedure by demonstrating on a
stuffed animal.
c. Help the child accept the loss of control ass o
ciated with hospitalization.
d. Help the child accept pain that is connected
with a treatment or procedure.
ANSWER: B
Preparing the child for any unfamiliar treatments, controlling pain, allowing privacy, providing
play activities for expression of fear and aggression, providing choices, and respecting cultural
differences are components of atraumatic care. In the provision of atraumatic care, the separation
of child from parents during hospitalization is minimized. The nurse should promote a sense of
control for the child. Preventing and minimizing bodily injury and pain are major components of
atraumatic care.
DIF: Cognitive Level: Understand REF: p. 8
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
11. Which is most suggestive that a nurse has a nontherapeutic relationship with a patient and fam-
ily?
, a. Staff is concerned about the nurse’s actions
with the patient and family.
b. Staff assignments allow the nurse to care for
same patient and family over an extended
time.
c. Nurse is able to withdraw emotionally when
emotional overload occurs but still remains
committed.
d. Nurse uses teaching skills to instruct patient
and family rather than doing everything for
them.
ANSWER: A
An clue to a nontherapeutic staff-patient relationship is concern of other staff members. Allowing
the nurse to care for the same patient over time would be therapeutic for the patient and family.
Nurses who are able to somewhat withdraw emotionally can protect themselves while providing
therapeutic care. Nurses using teaching skills to instruct patient and family will assist in transi-
tioning the child and family to self-care.
DIF: Cognitive Level: Analyze REF: p. 8
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
12. Which is most descriptive of clinical reasoning?
a. A simple developmental process
b. Purposeful and goal-directed
c. Based on deliberate and irrational thought
d. Assists individuals in guessing what is most
appropriate
ANSWER: B
Clinical reasoning is a complex, developmental process based on rational and deliberate thought.
Clinical reasoning is not a developmental process. Clinical reasoning is based on rational and de-
liberate thought. Clinical reasoning is not a guessing process.
DIF: Cognitive Level: Understand REF: p. 10
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
13. A nurse makes the decision to apply a topical anesthetic to a child’s skin before drawing blood.
Which ethical principle is the nurse demonstrating?
a. Autonomy
b. Beneficence
c. Justice
d. Truthfulness
ANSWER: B
Beneficence is the obligation to promote the patient’s well-being. Applying a topical anesthetic
before drawing blood promotes reducing the discomfort of the venipuncture. Autonomy is the
, patient’s right to be self-governing. Justice is the concept of fairness. Truthfulness is the concept
of honesty.
DIF: Cognitive Level: Understand REF: p. 10
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity
14. Which action by the nurse demonstrates use of evidence-based practice (EBP)?
a. Gathering equipment for a procedure
b. Documenting changes in a patient’s status
c. Questioning the use of daily central line
dressing changes
d. Clarifying a physician’s prescription for mor
phine
ANSWER: C
The nurse who questions the daily central line dressing change is ascertaining whether clinical
interventions result in positive outcomes for patients. This demonstrates EBP, which implies
questioning why something is effective and whether a better approach exists. Gathering equip-
ment for a procedure and documenting changes in a patient’s status are practices that follow es-
tablished guidelines. Clarifying a physician’s prescription for morphine constitutes safe nursing
care.
DIF: Cognitive Level: Apply REF: p. 10
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
15. A nurse is admitting a toddler to the hospital. The toddler is with both parents and is currently sit-
ting comfortably on a parent’s lap. The parents state they will need to leave for a brief period.
Which type of nursing diagnosis should the nurse formulate for this child?
a. Risk for anxiety
b. Anxiety
c. Readiness for enhanced coping
d. Ineffective coping
ANSWER: A
A potential problem is categorized as a risk. The toddler has a risk to become anxious when the
parents leave. Nursing interventions will be geared toward reducing the risk. The child is not
showing current anxiety or ineffective coping. The child is not at a point for readiness for en-
hanced coping, especially because the parents will be leaving.
DIF: Cognitive Level: Remember REF: p. 11
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A child has a postoperative appendectomy incision covered by a dressing. The nurse has just
completed a prescribed dressing change for this child. Which description is an accurate docu-
mentation of this procedure?
a. Dressing change to appendectomy incision
, completed, child tolerated procedure well,
parent present
b. No complications noted during dressing
change to appendectomy incision
c. Appendectomy incision non-reddened, su-
tures intact, no drainage noted on old dress-
ing, new dressing applied, procedure tolerat ed
well by child
d. No changes to appendectomy incisional area,
dressing changed, child complained of pain
during procedure, new dressing clean, dry and
intact
ANSWER: C
The nurse should document assessments and reassessments. Appearance of the incision described
in objective terms should be included during a dressing change. The nurse should document pa-
tient’s response and the outcomes of the care provided. In this example, these include drainage
on the old dressing, the application of the new dressing, and the child’s response. The other state-
ments partially fulfill the requirements of documenting assessments and reassessments, patient’s
response, and outcome, but do not include all three.
DIF: Cognitive Level: Analyze REF: p. 12
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
17. A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is
the priority for this class?
a. Appropriate use of car seat restraints
b. Safety crossing the street
c. Helmet use when riding a bicycle
d. Poison control numbers
ANSWER: A
Motor vehicle accidents (MVAs) continue to be the most common cause of death in children
older than 1 year, therefore the priority topic is appropriate use of car seat restraints. Safety
crossing the street and bicycle helmet use are topics that should be included for preschool parents
but are not priorities for parents of toddlers. Information about poison control is important for
parents of toddlers and would be a safety topic to include but is not the priority over appropriate
use of car seat restraints.
DIF: Cognitive Level: Apply REF: p. 3
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. A nurse is collecting subjective and objective information about target populations to diagnose
problems based on community needs. This describes which step in the community nursing
process?
a. Planning
, b. Diagnosis
c. Assessment
d. Establishing objectives
ANSWER: C
The nursing process stages are similar, whether the client is one child or a population of children.
The assessment phase of the nursing process focuses on collecting subjective and objective data.
Planning is the development of community-centered goals and objectives. Diagnosis is the iden-
tification of problems specific to the community.
DIF: Cognitive Level: Understand REF: p. 11
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
19. A nurse is establishing several health programs, such as bicycle safety, to improve the health sta-
tus of a target population. This describes which step in the community nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANSWER: D
The nurse working with the community to put into practice a program to reach community goals
is the implementation phase of the community nursing process. Planning involves designing the
program to meet community-centered goals. The evaluation stage would determine the effective-
ness of the program. During the assessment phase, the nurse would identify the resources neces-
sary and the barriers that would interfere with implementation.
DIF: Cognitive Level: Understand REF: p. 11
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
20. A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of
prevention is the nurse demonstrating?
a. Primary
b. Secondary
c. Tertiary
d. Health promotion
ANSWER: B
Secondary prevention focuses on screening and early diagnosis of disease. Vision and hearing
testing are screening tests to detect problems. Primary prevention focuses on health promotion
and prevention of disease or injury. Tertiary prevention focuses on optimizing function for chil-
dren with a disability or chronic disease. Health promotion is focused on preventing disease or
illness.
DIF: Cognitive Level: Understand REF: p. 2
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
11th Edition, Marilyn Hockenberry, Cheryl Rodgers Chapters
1 - 31
,
,Chapter 01: Perspectives of Pediatric Nursing
Hockenberry: Wong’s Essentials of Pediatric Nursing, 11th Edition
MULTIPLE CHOICE
1. A nurse is planning a teaching session for parents of preschool children. Which statement ex-
plains why the nurse should include information about morbidity and mortality?
a. Life span statistics are included in the data.
b. It explains effectiveness of treatment.
c. Cost-effective treatment is detailed for the
general population.
d. High-risk age groups for certain disorders or
hazards are identified.
ANSWER: D
Analysis of morbidity and mortality data provides the parents with information about which
groups of individuals are at risk for which health problems. Life span statistics is a part of the
mortality data. Treatment modalities and cost are not included in morbidity and mortality data.
DIF: Cognitive Level: Apply REF: p. 11
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
2. A clinic nurse is planning a teaching session about childhood obesity prevention for parents of
school-age children. The nurse should include which associated risk of obesity in the teaching
plan?
a. Type I diabetes
b. Respiratory disease
c. Celiac disease
d. Type II diabetes
ANSWER: D
Childhood obesity has been associated with the rise of type II diabetes in children. Type I dia-
betes is not associated with obesity and has a genetic component. Respiratory disease is not asso-
ciated with obesity, and celiac disease is the inability to metabolize gluten in foods and is not as-
sociated with obesity.
DIF: Cognitive Level: Apply REF: p. 2
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Which is the leading cause of death in infants younger than 1 year?
a. Congenital anomalies
b. Sudden infant death syndrome
c. Respiratory distress syndrome
d. Bacterial sepsis of the newborn
ANSWER: A
, Congenital anomalies account for 20.1% of deaths in infants younger than 1 year. Sudden infant
death syndrome accounts for 8.2% of deaths in this age group. Respiratory distress syndrome ac-
counts for 3.4% of deaths in this age group. Infections specific to the perinatal period account for
2.7% of deaths in this age group.
DIF: Cognitive Level: Remember REF: p. 6
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which leading cause of death topic should the nurse emphasize to a group of African-American
boys ranging in age from 15 to 19 years?
a. Suicide
b. Cancer
c. Firearm homicide
d. Occupational injuries
ANSWER: C
Firearm homicide is the second overall cause of death in this age group and the leading cause of
death in African-American males. Suicide is the third-leading cause of death in this population.
Cancer, although a major health problem, is the fourth-leading cause of death in this age group.
Occupational injuries do not contribute to a significant death rate for this age group.
DIF: Cognitive Level: Understand REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
5. Which is the major cause of death for children older than 1 year?
a. Cancer
b. Heart disease
c. Unintentional injuries
d. Congenital anomalies
ANSWER: C
Unintentional injuries (accidents) are the leading cause of death after age 1 year through adoles-
cence. Congenital anomalies are the leading cause of death in those younger than 1 year. Cancer
ranks either second or fourth, depending on the age group, and heart disease ranks fifth in the
majority of the age groups.
DIF: Cognitive Level: Remember REF: p. 7
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
6. Which is the leading cause of death from unintentional injuries for females ranging in age from 1
to 14?
a. Mechanical suffocation
b. Drowning
c. Motor vehicle–related fatalities
d. Fire- and burn-related fatalities
, ANSWER: C
Motor vehicle–related fatalities are the leading cause of death for females ranging in age from 1
to 14, either as passengers or as pedestrians. Mechanical suffocation is fourth or fifth, depending
on the age. Drowning is the second- or third-leading cause of death, depending on the age. Fire-
and burn-related fatalities are the second-leading cause of death.
DIF: Cognitive Level: Remember REF: p. 3
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
7. Which factor most impacts the type of injury a child is susceptible to, according to the child’s
age?
a. Physical health of the child
b. Developmental level of the child
c. Educational level of the child
d. Number of responsible adults in the home
ANSWER: B
The child’s developmental stage determines the type of injury that is likely to occur. The child’s
physical health may facilitate the child’s recovery from an injury but does not impact the type of
injury. Educational level is related to developmental level, but it is not as important as the child’s
developmental level in determining the type of injury. The number of responsible adults in the
home may affect the number of unintentional injuries, but the type of injury is related to the
child’s developmental stage.
DIF: Cognitive Level: Understand REF: p. 3
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
8. Which is now referred to as the “new morbidity”?
a. Limitations in the major activities of daily
living
b. Unintentional injuries that cause chronic
health problems
c. Discoveries of new therapies to treat health
problems
d. Behavioral, social, and educational problem s
that alter health
ANSWER: D
The new morbidity reflects the behavioral, social, and educational problems that interfere with
the child’s social and academic development. It is currently estimated that the incidence of these
issues is from 5% to 30%. Limitations in major activities of daily living and unintentional in-
juries that result in chronic health problems are included in morbidity data. Discovery of new
therapies would be reflected in changes in morbidity data over time.
DIF: Cognitive Level: Remember REF: p. 2
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance
, 9. A nurse on a pediatric unit is practicing family-centered care. Which is most descriptive of the
care the nurse is delivering?
a. Taking over total care of the child to reduce
stress on the family
b. Encouraging family dependence on health
care systems
c. Recognizing that the family is the constant i n
a child’s life
d. Excluding families from the decision-making
process
ANSWER: C
The three key components of family-centered care are respect, collaboration, and support. Fam-
ily-centered care recognizes the family as the constant in the child’s life. Taking over total care
does not include the family in the process and may increase stress instead of reducing stress. The
family should be enabled and empowered to work with the health care system. The family is ex-
pected to be part of the decision-making process.
DIF: Cognitive Level: Remember REF: p. 7
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
10. The nurse is preparing an in-service education to staff about atraumatic care for pediatric pa-
tients. Which intervention should the nurse include?
a. Prepare the child for separation from parent s
during hospitalization by reviewing a video.
b. Prepare the child before any unfamiliar trea t
ment or procedure by demonstrating on a
stuffed animal.
c. Help the child accept the loss of control ass o
ciated with hospitalization.
d. Help the child accept pain that is connected
with a treatment or procedure.
ANSWER: B
Preparing the child for any unfamiliar treatments, controlling pain, allowing privacy, providing
play activities for expression of fear and aggression, providing choices, and respecting cultural
differences are components of atraumatic care. In the provision of atraumatic care, the separation
of child from parents during hospitalization is minimized. The nurse should promote a sense of
control for the child. Preventing and minimizing bodily injury and pain are major components of
atraumatic care.
DIF: Cognitive Level: Understand REF: p. 8
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity
11. Which is most suggestive that a nurse has a nontherapeutic relationship with a patient and fam-
ily?
, a. Staff is concerned about the nurse’s actions
with the patient and family.
b. Staff assignments allow the nurse to care for
same patient and family over an extended
time.
c. Nurse is able to withdraw emotionally when
emotional overload occurs but still remains
committed.
d. Nurse uses teaching skills to instruct patient
and family rather than doing everything for
them.
ANSWER: A
An clue to a nontherapeutic staff-patient relationship is concern of other staff members. Allowing
the nurse to care for the same patient over time would be therapeutic for the patient and family.
Nurses who are able to somewhat withdraw emotionally can protect themselves while providing
therapeutic care. Nurses using teaching skills to instruct patient and family will assist in transi-
tioning the child and family to self-care.
DIF: Cognitive Level: Analyze REF: p. 8
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Psychosocial Integrity
12. Which is most descriptive of clinical reasoning?
a. A simple developmental process
b. Purposeful and goal-directed
c. Based on deliberate and irrational thought
d. Assists individuals in guessing what is most
appropriate
ANSWER: B
Clinical reasoning is a complex, developmental process based on rational and deliberate thought.
Clinical reasoning is not a developmental process. Clinical reasoning is based on rational and de-
liberate thought. Clinical reasoning is not a guessing process.
DIF: Cognitive Level: Understand REF: p. 10
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
13. A nurse makes the decision to apply a topical anesthetic to a child’s skin before drawing blood.
Which ethical principle is the nurse demonstrating?
a. Autonomy
b. Beneficence
c. Justice
d. Truthfulness
ANSWER: B
Beneficence is the obligation to promote the patient’s well-being. Applying a topical anesthetic
before drawing blood promotes reducing the discomfort of the venipuncture. Autonomy is the
, patient’s right to be self-governing. Justice is the concept of fairness. Truthfulness is the concept
of honesty.
DIF: Cognitive Level: Understand REF: p. 10
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiological Integrity
14. Which action by the nurse demonstrates use of evidence-based practice (EBP)?
a. Gathering equipment for a procedure
b. Documenting changes in a patient’s status
c. Questioning the use of daily central line
dressing changes
d. Clarifying a physician’s prescription for mor
phine
ANSWER: C
The nurse who questions the daily central line dressing change is ascertaining whether clinical
interventions result in positive outcomes for patients. This demonstrates EBP, which implies
questioning why something is effective and whether a better approach exists. Gathering equip-
ment for a procedure and documenting changes in a patient’s status are practices that follow es-
tablished guidelines. Clarifying a physician’s prescription for morphine constitutes safe nursing
care.
DIF: Cognitive Level: Apply REF: p. 10
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
15. A nurse is admitting a toddler to the hospital. The toddler is with both parents and is currently sit-
ting comfortably on a parent’s lap. The parents state they will need to leave for a brief period.
Which type of nursing diagnosis should the nurse formulate for this child?
a. Risk for anxiety
b. Anxiety
c. Readiness for enhanced coping
d. Ineffective coping
ANSWER: A
A potential problem is categorized as a risk. The toddler has a risk to become anxious when the
parents leave. Nursing interventions will be geared toward reducing the risk. The child is not
showing current anxiety or ineffective coping. The child is not at a point for readiness for en-
hanced coping, especially because the parents will be leaving.
DIF: Cognitive Level: Remember REF: p. 11
TOP: Integrated Process: Nursing Process: Diagnosis
MSC: Area of Client Needs: Health Promotion and Maintenance
16. A child has a postoperative appendectomy incision covered by a dressing. The nurse has just
completed a prescribed dressing change for this child. Which description is an accurate docu-
mentation of this procedure?
a. Dressing change to appendectomy incision
, completed, child tolerated procedure well,
parent present
b. No complications noted during dressing
change to appendectomy incision
c. Appendectomy incision non-reddened, su-
tures intact, no drainage noted on old dress-
ing, new dressing applied, procedure tolerat ed
well by child
d. No changes to appendectomy incisional area,
dressing changed, child complained of pain
during procedure, new dressing clean, dry and
intact
ANSWER: C
The nurse should document assessments and reassessments. Appearance of the incision described
in objective terms should be included during a dressing change. The nurse should document pa-
tient’s response and the outcomes of the care provided. In this example, these include drainage
on the old dressing, the application of the new dressing, and the child’s response. The other state-
ments partially fulfill the requirements of documenting assessments and reassessments, patient’s
response, and outcome, but do not include all three.
DIF: Cognitive Level: Analyze REF: p. 12
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
17. A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is
the priority for this class?
a. Appropriate use of car seat restraints
b. Safety crossing the street
c. Helmet use when riding a bicycle
d. Poison control numbers
ANSWER: A
Motor vehicle accidents (MVAs) continue to be the most common cause of death in children
older than 1 year, therefore the priority topic is appropriate use of car seat restraints. Safety
crossing the street and bicycle helmet use are topics that should be included for preschool parents
but are not priorities for parents of toddlers. Information about poison control is important for
parents of toddlers and would be a safety topic to include but is not the priority over appropriate
use of car seat restraints.
DIF: Cognitive Level: Apply REF: p. 3
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance
18. A nurse is collecting subjective and objective information about target populations to diagnose
problems based on community needs. This describes which step in the community nursing
process?
a. Planning
, b. Diagnosis
c. Assessment
d. Establishing objectives
ANSWER: C
The nursing process stages are similar, whether the client is one child or a population of children.
The assessment phase of the nursing process focuses on collecting subjective and objective data.
Planning is the development of community-centered goals and objectives. Diagnosis is the iden-
tification of problems specific to the community.
DIF: Cognitive Level: Understand REF: p. 11
TOP: Integrated Process: Communication and Documentation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
19. A nurse is establishing several health programs, such as bicycle safety, to improve the health sta-
tus of a target population. This describes which step in the community nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANSWER: D
The nurse working with the community to put into practice a program to reach community goals
is the implementation phase of the community nursing process. Planning involves designing the
program to meet community-centered goals. The evaluation stage would determine the effective-
ness of the program. During the assessment phase, the nurse would identify the resources neces-
sary and the barriers that would interfere with implementation.
DIF: Cognitive Level: Understand REF: p. 11
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
20. A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of
prevention is the nurse demonstrating?
a. Primary
b. Secondary
c. Tertiary
d. Health promotion
ANSWER: B
Secondary prevention focuses on screening and early diagnosis of disease. Vision and hearing
testing are screening tests to detect problems. Primary prevention focuses on health promotion
and prevention of disease or injury. Tertiary prevention focuses on optimizing function for chil-
dren with a disability or chronic disease. Health promotion is focused on preventing disease or
illness.
DIF: Cognitive Level: Understand REF: p. 2
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance
