Nurs 232 Exam 3 Questions With Complete Solutions
A 4 yr child's sibling dies from SIDS and the parents are
concerned bc the child showed more outward grief when their
cat died than for the sibling's death. Based on the nurse's
knowledge of development, the nurse explains that
a) this behavior suggests maladaptive coping, and a referral is
needed for counseling
b) the child is not old enough to have a concept of death
c) the child is not old enough to have formed a significant
attachment to her sibling
d) the death may be so painful and threatening that the child
must deny it for now to protect her psyche Correct Answers b)
the child is not old enough to have a concept of death
*death is permanent= 6 yrs; adult understanding=9 to 10 yrs
A 4 yr old child has ingested a toxic dose of iron. The parent
reports that the child vomited and complained of gastric pain an
hour ago but "feels fine" now. The parent is not certain when the
child ingested the iron tablets. The most appropriate
recommendation by the nurse to the parent is to
a) observe the child closely for 2 more hours
b) bring the child to the hospital immediately
c) administer activated charcoal
d) administer ipecac to induce vomiting if the child does not
vomit again within 1 hour Correct Answers b) bring the child to
the hospital immediately
*for assessment and possible gastric lavage.
*The period of concern for complications of iron toxicity is from
30 minutes to 6 hours.
,*Activated charcoal does not bind iron and is not a course of
treatment for this child.
*Ipecac is not recommended for poisonings.
A 4 yr old has been admitted to acute care setting w diagnosis of
leukemia. Which room assignment is best for pt?
a) 4 yr old w/ juvenille ITP
b) 4 yr old who also has leukemia
c) alone in private room
d) 5 yr old post appendectomy Correct Answers c) alone in
private room
*will eventually want pt to interact w peers and other children w
disease, but want minimize contact w others bc high risk of
infection from decreased WBC
A 4-year-old's concept of death is that
a) death is temporary
b) death is permanent
c) death is personified in various forms
d) death is inevitable at some age Correct Answers a) death is
temporary
*The concept that death is permanent by 6 yrs and the
inevitability of death is more representative of the understanding
of 9-10 yrs old
A 6 yr old girl has been receiving chemotherapy. She is also
receiving TPN via a central line. Which of the following nursing
diagnoses is the highest priority?
a) Imbalances nutrition: less than body requirements
b) risk for deficient fluid volume
c) risk for infection
,d) activity intolerance Correct Answers c) risk for infection
A 6 yr old pt is admitted w diagnosis of acute lymphocytic
leukemia (ALL). Monitoring for which condition is nurse's
higihest priority?
a) pain
b) infection
c) anemia
d) hemorrhage Correct Answers b) infection
*highest risk for infection r/t decreased WBC from destruction
A 9 yr old boy has several physical disabilities. His father
explains to the nurse that his son concentrates on what he can
do, rather than what he cannot do, and is as independent as
possible. Based on the nurse's knowledge of family-centered
care and various disabilities, the nurse interprets the child's
behavior and father's attitude as that the
a) father is experiencing denial
b) child is using an adaptive coping style
c) child is using a maladaptive coping style
d) father is experiencing grief Correct Answers b) child is using
an adaptive coping style
A child has a NG tube after surgery for acute appendicitis. What
is the purpose of the NG tube?
a) Maintain electrolyte balance
b) Maintain an accurate record of output
c) Prevent the spread of infection
d) Prevent abd distention Correct Answers d) Prevent abd
distention
, *used to maintain gastric decompression until intestinal activity
returns
*may adversely affect electrolyte balance by removing stomach
secretions
A child has frequent nose bleeds w/out warning producing
varying amount of blood. Inspection of the nose area reveals
irritated mucosa but no evidence of picking or trauma. The child
has no hx of allergic rhinitis or upper respiratory infections.
Denies taking any medication, either prescribed or over the
counter. Based on this information the nurse would:
a) maintain wait full management as most nose bleeds originate
from anterior portion of nose.
b) suggest that the patient use humidification to prevent dryness
of nasal passages.
c) consider referral to ENT for evaluation for other
comorbidities.
d) increase fluid content to maintain humidification as this may
be due to environmental dryness. Correct Answers c) consider
referral to ENT for evaluation for other comorbidities.
*alerts the nurse that there may be other underlying
comorbidities such as leukemia, thrombocytopenia, and clotting
factor deficiencies like Von Willebrand Disease
A child is coming to the clinic w parents for a sports physical.
Upon reviewing the pts hx, there is a notation that the child has
been recently treated 6 mos ago for ITP. Based on this info, the
nurse would provide this recommendation?
a) The child should not play any sports or participate in any
physical activity while in school
A 4 yr child's sibling dies from SIDS and the parents are
concerned bc the child showed more outward grief when their
cat died than for the sibling's death. Based on the nurse's
knowledge of development, the nurse explains that
a) this behavior suggests maladaptive coping, and a referral is
needed for counseling
b) the child is not old enough to have a concept of death
c) the child is not old enough to have formed a significant
attachment to her sibling
d) the death may be so painful and threatening that the child
must deny it for now to protect her psyche Correct Answers b)
the child is not old enough to have a concept of death
*death is permanent= 6 yrs; adult understanding=9 to 10 yrs
A 4 yr old child has ingested a toxic dose of iron. The parent
reports that the child vomited and complained of gastric pain an
hour ago but "feels fine" now. The parent is not certain when the
child ingested the iron tablets. The most appropriate
recommendation by the nurse to the parent is to
a) observe the child closely for 2 more hours
b) bring the child to the hospital immediately
c) administer activated charcoal
d) administer ipecac to induce vomiting if the child does not
vomit again within 1 hour Correct Answers b) bring the child to
the hospital immediately
*for assessment and possible gastric lavage.
*The period of concern for complications of iron toxicity is from
30 minutes to 6 hours.
,*Activated charcoal does not bind iron and is not a course of
treatment for this child.
*Ipecac is not recommended for poisonings.
A 4 yr old has been admitted to acute care setting w diagnosis of
leukemia. Which room assignment is best for pt?
a) 4 yr old w/ juvenille ITP
b) 4 yr old who also has leukemia
c) alone in private room
d) 5 yr old post appendectomy Correct Answers c) alone in
private room
*will eventually want pt to interact w peers and other children w
disease, but want minimize contact w others bc high risk of
infection from decreased WBC
A 4-year-old's concept of death is that
a) death is temporary
b) death is permanent
c) death is personified in various forms
d) death is inevitable at some age Correct Answers a) death is
temporary
*The concept that death is permanent by 6 yrs and the
inevitability of death is more representative of the understanding
of 9-10 yrs old
A 6 yr old girl has been receiving chemotherapy. She is also
receiving TPN via a central line. Which of the following nursing
diagnoses is the highest priority?
a) Imbalances nutrition: less than body requirements
b) risk for deficient fluid volume
c) risk for infection
,d) activity intolerance Correct Answers c) risk for infection
A 6 yr old pt is admitted w diagnosis of acute lymphocytic
leukemia (ALL). Monitoring for which condition is nurse's
higihest priority?
a) pain
b) infection
c) anemia
d) hemorrhage Correct Answers b) infection
*highest risk for infection r/t decreased WBC from destruction
A 9 yr old boy has several physical disabilities. His father
explains to the nurse that his son concentrates on what he can
do, rather than what he cannot do, and is as independent as
possible. Based on the nurse's knowledge of family-centered
care and various disabilities, the nurse interprets the child's
behavior and father's attitude as that the
a) father is experiencing denial
b) child is using an adaptive coping style
c) child is using a maladaptive coping style
d) father is experiencing grief Correct Answers b) child is using
an adaptive coping style
A child has a NG tube after surgery for acute appendicitis. What
is the purpose of the NG tube?
a) Maintain electrolyte balance
b) Maintain an accurate record of output
c) Prevent the spread of infection
d) Prevent abd distention Correct Answers d) Prevent abd
distention
, *used to maintain gastric decompression until intestinal activity
returns
*may adversely affect electrolyte balance by removing stomach
secretions
A child has frequent nose bleeds w/out warning producing
varying amount of blood. Inspection of the nose area reveals
irritated mucosa but no evidence of picking or trauma. The child
has no hx of allergic rhinitis or upper respiratory infections.
Denies taking any medication, either prescribed or over the
counter. Based on this information the nurse would:
a) maintain wait full management as most nose bleeds originate
from anterior portion of nose.
b) suggest that the patient use humidification to prevent dryness
of nasal passages.
c) consider referral to ENT for evaluation for other
comorbidities.
d) increase fluid content to maintain humidification as this may
be due to environmental dryness. Correct Answers c) consider
referral to ENT for evaluation for other comorbidities.
*alerts the nurse that there may be other underlying
comorbidities such as leukemia, thrombocytopenia, and clotting
factor deficiencies like Von Willebrand Disease
A child is coming to the clinic w parents for a sports physical.
Upon reviewing the pts hx, there is a notation that the child has
been recently treated 6 mos ago for ITP. Based on this info, the
nurse would provide this recommendation?
a) The child should not play any sports or participate in any
physical activity while in school
