Health Care Adaptations for the Child and Family (Chapter 22)

MULTIPLE CHOICE 1. What is the best pulse location for the nurse to use when assessing the pulse rate on a 12- month-old infant? a. Brachial b. Apical c. Radial d. Femoral ANS: B Apical pulses are advised for children under age 5 years. DIF: Cognitive Level: Knowledge REF: Page 491 OBJ: 4 TOP: Physical Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the child’s name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet. ANS: C After confirmation of the child’s identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment. DIF: Cognitive Level: Application REF: Page 486 | Page 507 | Page 513 OBJ: 2 TOP: ID Bracelets KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions? a. “I should wash my perineum with soap and water, then begin to urinate.” b. “I clean the perineum from front to back with an antiseptic wipe before I urinate.” c. “I’ll collect the first stream of urine in a sterile container.” d. “I will discard the first void and collect a freshly voided specimen 30 minutes later.” ANS: B To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back. DIF: Cognitive Level: Analysis REF: Page 497 OBJ: 2 TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. Which strategy might the nurse use when administering oral medications to a young child who is reluctant? a. Mix the medication with chocolate milk. b. Tell the child that the medication is candy. c. Give the medication quickly if the child is crying. d. Offer the child fruit juice after the medication is swallowed. ANS: D The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk because the child may develop distaste for it. DIF: Cognitive Level: Application REF: Page 501 OBJ: 2 TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A parent tells the nurse, “I’m not sure how to give this medicine to my infant.” How would the nurse teach the parent to best administer an oral suspension? a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and placing the medication in the side of the infant’s mouth. d. Administer the medication with a dropper onto the back of the infant’s tongue. ANS: C An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is placed midway back, at the side of the mouth. DIF: Cognitive Level: Application REF: Page 502 OBJ: 10 TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out ANS: A For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.