Pediatric Nursing An Introductory Text 11th edition by Debra L. Price Test Bank

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Pediatric Nursing An Introductory Text 11th edition by Debra L. Price Test Bank

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Pediatric Nursing An Introductory Text 11th edition by Debra L. Price

Price: Pediatric Nursing, 11th Edition

 

Chapter 02: Care of the Child with Medical/Surgical Needs

 

Testbank

 

MULTIPLE CHOICE

 

  1. A nurse who may have a private practice in the office of a pediatrician or a family practice physician is:
a. A school nurse
b. A home health nurse
c. A pediatric nurse practitioner
d. Any licensed LVN or RN

 

 

ANS:   C

A pediatric nurse practitioner may conduct a private practice in the office of a pediatrician or family practice physician performing physical examinations and general well-child services such as school-based clinics or health clinics.

 

DIF:    Cognitive Level: Application             REF:    p. 8                  OBJ:    2

TOP:    The Pediatric Nurse Practitioner        KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A newly admitted 5-year-old asks if he can wear his cowboy shirt. The nurses response will be based on the understanding that wearing his own clothes will
a. Make child feel more comfortable
b. Present an infection control problem
c. Make caring for the child more difficult
d. Not be permitted

 

 

ANS:   A

Allowing the child to wear his own clothes helps to bridge the gap between home and hospital. Wearing clothes from home should not pose an infection control problem. The nurse can assess the clothing and determine if this is a risk.

 

DIF:    Cognitive Level: Application             REF:    p. 10                OBJ:    4

TOP:    The Hospital Setting                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A 4-year-old is going to have a dressing change that may be painful and frightening, therefore the nurse will perform this procedure in:
a. The patient room, because the surroundings are familiar
b. The treatment room, so the child will not associate negative feelings with the patient room
c. The playroom, so the child will be distracted by other children
d. A screened-off area in the hall to reduce visual stimulation

 

 

ANS:   B

Painful and frightening procedures are accomplished in the treatment room. The child needs to feel safe and secure in the patient room. Performing the procedure in front of other children is inappropriate.

 

DIF:    Cognitive Level: Application             REF:    pp. 11-12         OBJ:    4

TOP:    The Hospital Setting                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse clarifies that the purpose of the pediatric unit playroom is to provide:
a. A safe place for children to go when the nurses take a break
b. An incentive for patients to choose this hospital
c. An activity area to alleviate the stress of hospitalization
d. An environment to determine if the child is well enough for discharge

 

 

ANS:   C

Playrooms provide a place for children to play and interact with other children. Many units include a play therapist or a child life specialist in attendance.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 10                OBJ:    3

TOP:    Playrooms       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse assesses that a 2-year-old who cries continuously after his mother leaves, watches the door for her return, and then finally exhausts himself and goes to sleep is in the separation anxiety phase of:
a. Despair
b. Denial
c. Protest
d. Depression

 

 

ANS:   C

The child is in the protest stage. Depression is not a stage of separation.

 

DIF:    Cognitive Level: Application             REF:    p. 11                OBJ:    3

TOP:    The Childs Reaction to Hospitalization

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The parents of a 3-year-old who is scheduled to have surgery the following week ask the home health nurse if a tour of the pediatric unit prior to the procedure is wise. The nurse responds:
a. Yes, because it allows the parents to meet the people that will be taking care of their child.
b. No, because it will overwhelm and frighten your child.
c. No, because it will be an infection control risk.
d. Yes, because parents will not be allowed to stay with the child in the hospital.

 

 

ANS:   A

A prehospitalization tour or class will help to alleviate the anxiety of the parent and child. The child will be with his parents during the tour. It is not an infection control risk. The parents will be encouraged to stay with the child.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 15                OBJ:    5

TOP:    The Familys Reaction to Hospitalization

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. When greeting a newly admitted pediatric patient and family, the nurse should:
a. Stand erect in a confident manner
b. Show warmth and friendliness to the child and family
c. Be polite and formal to show respect
d. Hurry through the interview to lessen the stress on the child

 

 

ANS:   B

The nurse will greet the child at eye level. Towering over the child is frightening. The nurse should be warm and friendly. The nurse should be calm and unhurried when talking with the child and family.

 

DIF:    Cognitive Level: Application             REF:    p. 16                OBJ:    4

TOP:    Therapeutic Relationships                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The school nurse would consider a recommendation for referral to Shriners Hospital to the parents of a child with:
a. A developmental retardation
b. A cleft lip
c. An orthopedic deformity
d. A behavioral problem

 

 

ANS:   C

Shriners Hospitals is a network of pediatric specialty hospitals in which children younger than 18 years of age with orthopedic conditions or burns are treated without cost.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    Shriners Hospitals                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The nurse performing a review of systems on an 8-month-old infant who is awake and calm should make the initial assessment:
a. Examination of the ears with an otoscope
b. Auscultation of the heart, lungs, and bowel sounds
c. Obtaining a rectal temperature
d. Palpation of the abdomen

 

 

ANS:   B

Auscultation of the heart, lungs, and abdomen should be the initial assessment as it is the least stressful, especially if the child has had an opportunity to handle the stethoscope.

 

DIF:    Cognitive Level: Application             REF:    p. 17                OBJ:    7

TOP:    Systems Review                                 KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When auscultating the heart of a 3-year-old girl, an irregular heartbeat is assessed. The nurse recognizes that:
a. This is normal for a child younger than 4 years of age
b. The arrhythmia should be documented and reported to the charge nurse
c. This may be caused by anxiety and should be rechecked in 1 hour
d. This is an emergency, and help should be called

 

 

ANS:   B

A child of 3 years of age should have a regular rhythm. An irregular heart rhythm should be documented and reported to the nurse in charge immediately. Arrhythmias do not pose an immediate threat.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 18                OBJ:    7

TOP:    Systems Review                                 KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When referring a child and family to a hospice service, the nurse considers that to qualify for hospice, the child must:
a. Have adequate insurance coverage
b. Be in an active therapeutic protocol
c. Have a terminal diagnosis
d. Have less than 6 months to live

 

 

ANS:   D

To qualify for hospice, a patient must have less than 6 months to live. These services are supplied either in the hospital or at home.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    Vital Signs      KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The parents of a hospitalized 2-year-old are distressed that the child no longer is toilet trained and now requires a diaper. The nurses best response to this would be:
a. Dont worry. Your child will regain toilet training in a few days.
b. We can start a bladder training program that will restore toilet training.
c. Toddlers often regress when stressed. Using a diaper now is appropriate.
d. You need to strongly enforce toilet training practices now.

 

 

ANS:   C

With the stress of hospitalization, toddlers may abandon recently acquired skills. When the stress is manageable, the skills will return.

 

DIF:    Cognitive Level: Application             REF:    p. 11                OBJ:    5

TOP:    Regression      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The parents of a 3-year-old who is hospitalized with mumps and is in isolation ask if their child may be allowed out of bed. The nurses most helpful response would be:
a. No. A child with an infectious disease needs to stay in bed.
b. Yes. Your child may go anywhere in the unit.
c. No. Your child will spread the mumps if allowed out of bed.
d. Yes. Your child can walk around here in the room, but not out in the hall.

 

 

ANS:   D

A toddler who feels like getting out of bed and walking should do so; however, keep in mind that a child with an infectious disease should stay within the confines of the room.

 

DIF:    Cognitive Level: Application             REF:    p. 12                OBJ:    10

TOP:    Toddler Activity                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When a 4-year-old asks the nurse if an injection will hurt, the most therapeutic response would be:
a. No. It is over so quickly you will not feel a thing.
b. Yes. You can see how sharp the needle is, so it will hurt when it goes in.
c. No. A big 4-year-old like you wont be bothered by a little needle stick.
d. Yes. There will be a little sting, but hugging this bear will help.

 

 

ANS:   D

The nurse should be truthful about procedures. Honesty helps the child not to feel betrayed. Preparation for a painful procedure should be done immediately before the procedure so as not to draw out the anticipation.

 

DIF:    Cognitive Level: Application             REF:    p. 12                OBJ:    4

TOP:    Preparation for a Painful Procedure

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The pediatric nurse takes into consideration that the most stressful procedure for a preschooler would be:
a. Casting a broken arm
b. Circumcision
c. Suturing a laceration on the hand
d. Removing sutures from the face

 

 

ANS:   B

Preschoolers fear mutilation during hospitalization, particularly invasive procedures that involve the genital area.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 12                OBJ:    5

TOP:    Preschoolers Fear of Mutilation        KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. After the nurse has lowered the crib rail on the bed of a 6-month-old, in order to prevent the child from rolling out of bed, the nurse should:
a. Restrain the child with a sheet
b. Stand touching the side of the bed
c. Place the child perpendicular to the side rail
d. Ask assistance from the parent or coworker to hold the child

 

 

ANS:   C

Placing the child perpendicular to the side rails prevents the child from rolling off the bed.

 

DIF:    Cognitive Level: Application             REF:    p. 22                OBJ:    9

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A 6-year-old newly diagnosed with Type I diabetes is going home today. Her parents have been taught how to manage her disease, but the nurse is concerned that they may not remember everything that was taught. The nurse can best help the parents by:
a. Instructing the parents that they can bring their child back to the unit for additional help as needed
b. Beginning discharge planning as soon as the order for discharge has been written by the attending physician
c. Providing the family with written instructions regarding diet, medications, activity, and procedures needed by the child
d. Delaying informing the parents of the impending discharge to prevent stress and anxiety for the parents and child

 

 

ANS:   C

Providing written instructions about all aspects of care will reinforce teaching and provide an important resource for the parents. The parents need to be informed of discharge as soon as possible so that they can begin making arrangements and can prepare for departure.

 

DIF:    Cognitive Level: Synthesis                REF:    p. 22                OBJ:    8

TOP:    Discharge Planning                            KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A child is admitted with an infectious disease and is placed in an isolation room. In order to assess this child, the nurse should:
a. Use his or her own stethoscope, and wipe it thoroughly with antiseptic after each use
b. Use a stethoscope reserved for this patient in the room
c. Use a sterile stethoscope each time the patient is assessed
d. Remove the used equipment each day for disinfection

 

 

ANS:   B

A patient in isolation will have equipment for daily care placed in the isolation room. A sterile stethoscope is not needed. Equipment is kept in the room until the patient is discharged. Removing the equipment daily will increase exposure risk to others.

 

DIF:    Cognitive Level: Application             REF:    p. 25                OBJ:    10

TOP:    Preventing the Transmission of Infection

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Because the child in isolation is not permitted to go to the playroom, the nurse explains that toys that are:
a. Brought from the playroom will have to be thrown away
b. Washable can be brought from the playroom and later disinfected
c. From the playroom must be sealed in a plastic bag
d. For the childs use must be brought from home

 

 

ANS:   B

The child can have toys when in isolation, but they must be washable. Children do not have to bring their own toys to play.

 

DIF:    Cognitive Level: Application             REF:    p. 25                OBJ:    10

TOP:    Preventing the Transmission of Infection

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The best restraint for an 8-month-old with sutures after the repair of a cleft lip would be:
a. Elbow restraint
b. Mummy restraint
c. Jacket restraint
d. No restraint at all

 

 

ANS:   A

The elbow restraint is the best choice as it is useful in the prevention of the child touching the face. Mummy or jacket restraints are excessive and not particularly helpful with a facial injury.

 

DIF:    Cognitive Level: Application             REF:    p. 24                OBJ:    11

TOP:    Restraints        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse is caring for a 5-year-old who had surgery yesterday. In order to evaluate the degree of pain the child is experiencing, the nurse will:
a. Expect the child to complain if she is in pain
b. Observe for verbal and nonverbal cues that the child is in pain
c. Give pain medication if the child is crying
d. Ask the child to rate her pain on a scale of 1 to 10

 

 

ANS:   B

Children do not always complain if they are in pain. They are frightened by the events and their surroundings. The nurse should evaluate for both verbal and nonverbal cues of pain. Children may not always cry if they are in pain. Conversely, they may be crying for another reason. Children at this age cannot rate their pain in this way. The nurse would use a pictorial pain scale.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 28                OBJ:    12

TOP:    The Child in Pain                                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse assesses an 8-month-old who had abdominal surgery yesterday as showing an occasional grimace, is kicking legs constantly, is squirming and tense, moans and whimpers occasionally, and is difficult to console. Using the FLACC scale, the nurse would document a score of:
a. 4
b. 5
c. 6
d. 7

 

 

ANS:   D

RAT: Occasional grimacing = 1, kicking = 2, squirming and tense = 1, occasional moaning = 1, difficult to console = 2. This is a total score of 7.

 

DIF:    Cognitive Level: Application             REF:    p. 29                OBJ:    11

TOP:    Pain Assessment (FLACC)                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse who is admitting a child with severe asthma is alarmed when the parents confess that they have been giving the child Echinacea because this herbal remedy may cause:
a. Severe headache
b. Increased asthma
c. Increased blood pressure
d. Liver inflammation

 

 

ANS:   B

The herbal remedy Echinacea may cause increased asthma or anaphylaxis.

 

DIF:    Cognitive Level: Application             REF:    p. 17                OBJ:    6

TOP:    Alternative Remedies                         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

COMPLETION

 

  1. The nurse recommends a method for children to act out situations that are part of their hospital experience through __________.

 

ANS:

Dramatic play

Dramatic play allows small children to work through emotions and stressors that they may not be able to verbalize.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 13                OBJ:    4

TOP:    The Childs Reaction to Hospitalization

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse takes into consideration that a Mexican-American family may seek the advice of a __________ , a folk healer, for treatment or herbal remedies.

 

ANS:

Curandero

The curandero is used by the Hispanic community as a folk healer or spiritual healer.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 19                OBJ:    5

TOP:    Curandero       KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

MULTIPLE RESPONSE

 

  1. The role of the school nurse has been expanded to include such services as: (Select all that apply.)
a. Provision of health counseling
b. Student advocate
c. Administration of selected immunizations
d. Health screenings
e. Complete physical examinations (system review)

 

 

ANS:   A, B, C, D

School nurses may provide health counseling and education and health screenings, and act as student advocate.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    Duties of the School Nurse                KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The school nurse recommends to a family that they consider the use of an outpatient clinic for the upcoming tonsillectomy of their child because the advantages of this service are: (Select all that apply.)
a. Reduction of risk of infection
b. Less stress to the child
c. Reduced cost
d. Requires no insurance coverage
e. No prolonged separation of the child from the family

 

 

ANS:   A, B, C, E

Outpatient surgery, although it may require insurance coverage, has the advantages of reduced risk of infection and reduced cost. The child is less stressed as there is no familial separation.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    3

TOP:    Outpatient Surgery                             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The nurse who is in the role of case manager has the responsibilities of: (Select all that apply.)
a. Making home care arrangements
b. Performing hands-on care of the patient in the home
c. Monitoring the continuum of care
d. Managing medical care
e. Assessing the needs of the patient and family

 

 

ANS:   A, C, D, E

The case manager arranges for home care by organizing medical care, assessing the needs of the patient and family, and organizing the availability of necessary equipment. The case manager does not do hands-on care.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    The Case Manager                              KEY:   Nursing Process Step: N/A

MSC:   NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The family of a hospitalized 12-year-old who has been burned confides to the nurse that the patients 6-year-old sister is distressed about where her brother has gone. They ask what might allay her fears. The nurse suggests: (Select all that apply.)
a. Allow the sister to visit in the hospital
b. Explain in detail about the painful surgery and necessary care
c. Encourage the sibling to send cards
d. Request that the patient call his sister on the telephone
e. Report the daily progress to the sibling

 

 

ANS:   A, C, D, E

Keeping siblings informed and in touch helps to allay concerns. Telephone calls and sending of cards is helpful. Explaining in detail about the treatment may increase anxiety in a sibling.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 15                OBJ:    5

TOP:    Sibling Concerns                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A patient in an isolation room is experiencing projectile vomiting. In order to assist this patient, the personal protective equipment that the nurse should don would be: (Select all that apply.)
a. Gloves
b. Mask
c. Gown
d. Protective eyewear
e. Head cover

 

 

ANS:   A, C, D

Standard precautions call for the use of gloves and gowns; because there is a problem with projectile vomiting, protective eyewear should be included. Head cover is not necessary.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 25-26         OBJ:    12

TOP:    Preventing the Spread of Infection    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse reviews nursing implementations that can help relieve the stressors of hospitalization for a child to include: (Select all that apply.)
a. Providing a consistent caregiver
b. Keeping explanations to a minimum
c. Encouraging parents to stay with the child
d. Discouraging play in order to keep the child calm
e. Allowing the child to make as many choices as possible

 

 

ANS:   A, C, E

Consistent caregivers, presence of the parent(s), and allowing as many choices as possible will relieve the stress of hospitalization. Explanations should be frequent and age-appropriate, and play should be encouraged.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 15                OBJ:    4

TOP:    The Childs Reaction to Hospitalization

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychological Integrity: Coping and Adaptation

 

 

Price: Pediatric Nursing, 11th Edition

 

Chapter 10: The Adolescent

 

Testbank

 

MULTIPLE CHOICE

 

  1. The nurse is aware that the Tanner staging system for sexual maturity is:
a. Based on the development of pubic hair in girls
b. More accurate than using chronological age
c. Based on staged voice changes in males
d. Based on measured color of pigmentation on the scrotum and areola

 

 

ANS:   A

The Tanner staging system for the measurement of sexual maturity is based on both breast and pubic hair development in girls and both genital and pubic hair development in boys.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 181              OBJ:    2

TOP:    General Characteristics and Development

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. The nurse reminds the parents of an adolescent that one of the developmental tasks of adolescence is detachment from parents. Parents can assist their teen with this process by:
a. Encouraging their teen to gain acceptance in a group of peers
b. Distancing themselves from the teen
c. Discouraging conformity with a peer group
d. Avoiding the use of family networking or community resources

 

 

ANS:   A

Teens should be encouraged to gain acceptance in a peer group. Parents should not distance themselves from the teen, even if the teen does not seem to want their help. Discouraging a teen from conforming to a peer group will make detachment from parents difficult. Community resources and family networking are excellent sources of help.

 

DIF:    Cognitive Level: Application             REF:    pp. 183-184     OBJ:    2

TOP:    Peer Relationships                              KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. To teach their teen the value of money and its responsibility, the nurse suggests that parents:
a. Provide the teen with an allowance or a bank account
b. Balance the teens checkbook for him or her
c. Hand out money as requested
d. Maintain the amount of allowance

 

 

ANS:   A

A teen should have an allowance. This will allow the teen to learn how to use money in a responsible way. If parents hand out money as asked, the child will not learn how to save or plan ahead. A teen should have the responsibility of balancing his or her own checkbook. Maintaining the amount of the allowance may not meet the needs of the maturing adolescent.

 

DIF:    Cognitive Level: Application             REF:    p. 186              OBJ:    5

TOP:    Responsibility                                     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. The nurse clarifies that the optimum time for a young man to perform a testicular exam is:
a. After the first voiding in the morning
b. After a hot bath or shower
c. After strenuous exercise
d. Before going to sleep at night

 

 

ANS:   B

The best time for a testicular exam is after a hot bath or shower as the scrotum is relaxed.

 

DIF:    Cognitive Level: Application             REF:    p. 183              OBJ:    5

TOP:    Testicular Exam                                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. The nurse is aware that when adolescents begin to become interested in the opposite sex, parents should consider:
a. Limiting the development of friendships with the opposite sex
b. The cultural influence on dating patterns
c. That group outings to the beach or mall are unrelated to heterosexual encounters
d. Imposing stringent restrictions on heterosexual encounters

 

 

ANS:   B

Adolescents need to learn how to develop relationships with the opposite sex. Cultural background can influence dating patterns. The primary goal of social outings at this age is to meet members of the opposite sex. Teens may turn to sexually acting out to test control if stringent restrictions are enforced.

 

DIF:    Cognitive Level: Application             REF:    p. 187              OBJ:    4

TOP:    Heterosexual Relationships                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. The school nurse offering a course about date rape should direct the focus of the class to:
a. Girls, because they can stop the rape if they say no
b. Boys, because they need to understand that girls want sex, even if they say no
c. Boys and girls so that they can understand how to protect themselves from this situation
d. Boys and girls so that they can understand that the date rape drug is a myth

 

 

ANS:   C

Boys may believe that girls want sex even if they say no, so boys need to be taught that this is not the case. Girls and boys should be taught that if the girl or boy says no, their wishes should be respected. The date rape drug is not a myth and is a very potent drug. It is illegal but is imported into this country.

 

DIF:    Cognitive Level: Application             REF:    p. 188              OBJ:    4

TOP:    Date Rape       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. A home health nurse planning the care for a disabled teen takes into consideration that the patient:
a. Is focused solely on dealing with the illness
b. Is concerned about being accepted by peers
c. Understands that keeping up with classmates is not possible
d. Needs a rigid routine to feel secure

 

 

ANS:   B

A disabled teen is still focused on acceptance. This teen has the additional burden of also dealing with a chronic health condition, which makes acceptance very difficult. The nurse should help the teen explore ways that he or she can keep up with his or her class. Peers should be encouraged to visit. The teen needs a flexible routine to allow for as much normality as possible.

 

DIF:    Cognitive Level: Application             REF:    p. 188              OBJ:    6

TOP:    Chronic Illness/Disability                   KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. A home care nurse caring for a disabled 16-year-old adolescent patient in his home would be especially mindful to:
a. Observe the patients facial expressions and body language
b. Avoid posting signs above the bed that state special considerations for care
c. Understand that the needs or concerns of other siblings in the home are not important
d. Limit the patients socialization with peers

 

 

ANS:   A

The nurse should observe for nonverbal cues as well as verbal cues when working with this patient. The nurse can facilitate care between various agencies and staff by placing signs about important aspects of care over the bed. This patient will have a difficult time maintaining peer relationships without the help and support of the care team. The home care nurse should also be tuned in to the needs of other siblings in the home.

 

DIF:    Cognitive Level: Application             REF:    p. 188              OBJ:    6

TOP:    Chronic Illness/Disability                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A father expresses concern about parenting his two teenage children. The nurse is guided in understanding parental issues with these teens because the nurse understands that:
a. The philosophy of parenting has remained unchanged for several generations
b. Parents need to be assured that all parents make mistakes
c. Parents should not change their own views to accommodate their children
d. As teens grow older, they are less able to develop a satisfying relationship with their parents

 

 

ANS:   B

The philosophy of parenting is constantly changing. Parents can make mistakes in parenting. If parents refuse to change their views to accommodate their children, bitterness and anger can follow. Teens can develop a progressively more satisfying relationship with their parent, with care.

 

DIF:    Cognitive Level: Application             REF:    p. 189              OBJ:    7

TOP:    Parenting a Teenager                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The frustrated mother of a 13-year-old girl confides in the school nurse, I am at my wits endone day my daughter is dressed up and acting very sophisticated, and the next she is in blue jeans playing football with her brothers. The nurses response is based on the fact that adolescents
a. Who demonstrate wide mood changes may have a mental disorder
b. Need guidance to help them select appropriate clothing
c. Who dress in clothing of the opposite sex may be experiencing a sexual identity crisis
d. Frequently try out identities seeking a comfortable fit for their own personality

 

 

ANS:   D

Adolescents in their search for their own identity will try out several personalities (personality diffusion).

 

DIF:    Cognitive Level: Application             REF:    p. 187              OBJ:    2

TOP:    Seeking Identity                                 KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. A teen is seen at the clinic for problems with a body piercing that was done several weeks ago. When assessing the site, which is swollen, red, and painful, the nurse should:
a. Tell the teen that body piercing is wrong
b. Ask the teen why he or she chose to have the piercing
c. Tell the teen that he or she should have gone to a professional
d. Ask the teen where the piercing was done

 

 

ANS:   D

Health professionals should not pass judgment on teens that choose to have body piercing. The most helpful response is to ask for additional information about where the piercing was done. If a friend or nonprofessional did the piercing, the teen may have a serious infection.

 

DIF:    Cognitive Level: Application             REF:    p. 191              OBJ:    9

TOP:    Body Piercing and Tattoos                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. When a teen asks the nurse if tattoos are safe, the nurses best response would be:
a. Tattoos are not professional, and you should not get one.
b. All tattoo parlors use sterile needles and gloves, and you dont need to worry.
c. There is a risk for tetanus, HIV, and hepatitis B if proper precautions are not taken.
d. Tattoos are only appropriate for boys. Nice girls shouldnt get one.

 

 

ANS:   C

The nurse should give accurate information. The nurse should not impose his or her own values on the teen. The nurse will not encourage discussion and exploration of ideas if the teen is not allowed to freely communicate.

 

DIF:    Cognitive Level: Application             REF:    p. 191              OBJ:    9

TOP:    Body Piercing and Tattoos                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A teen who has just had a body piercing asks the school nurse if it is okay to swap jewelry with her friends. The nurses best response would be:
a. Be sure that you share jewelry with someone you know is not sick.
b. Never share jewelry with someone else.
c. If you share jewelry with a friend, be sure to clean the jewelry with alcohol before inserting it.
d. Only use solid gold jewelry to prevent a reaction.

 

 

ANS:   B

Teens should be instructed to never share jewelry with another person. Cleaning with alcohol will not remove all organisms. Gold jewelry only is of benefit if a person is allergic to nickel or silver. It will not prevent contamination.

 

DIF:    Cognitive Level: Application             REF:    p. 191              OBJ:    9

TOP:    Body Piercing and Tattoos                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The school nurse takes into consideration that nutritional information for adolescents can be problematic as adolescent boys have different nutrition concerns than adolescent girls, such as:
a. Girls have more caloric requirements than boys
b. Boys dont care about what they eat
c. Girls dont have body image concerns
d. Boys are focused on body building

 

 

ANS:&n

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