Question 1

Which intervention should the nurse use when collecting a urine specimen from an 8-month-old patient?

Accepted Answer

An infant who has not been toilet trained cannot be expected to urinate on command so a collecting device must be attached to the genitalia to collect their next voiding. Most infants void shortly after a feeding, so if the collector is applied just before a regular feeding, voiding will probably result soon afterward. Remove the collector as soon as the infant voids and transfer the specimen to a specimen cup by cutting a bottom corner of the bag. Waiting an hour after a feeding might not produce the needed urine for the specimen. It would be difficult to obtain a clean-catch specimen from a baby. It is inappropriate to send a saturated diaper to the laboratory for a urine specimen.

Question 2

The nurse needs to obtain a blood sample from a 7-year-old child. How should the nurse explain this procedure to the patient?

Accepted Answer

The nurse should offer the child a simple explanation of the procedure such as, "The doctor needs to look at your blood to see why you are sick; it will only hurt for a second." The nurse needs to let the child know you understand how difficult it is to agree to the procedure. Saying that the procedure does not hurt is not being truthful. Asking the patient to hold still does not provide enough of an explanation about the venipuncture. Saying that the technician is going to draw the blood and that it will only hurt for a minute does not explain why the blood is needed.

Question 3

The nurse is preparing a community program for parents and children that focus on the 2020 National Health Goals to reduce the number of diagnostic or therapeutic procedures. Which topics should the nurse include in this program? (Select all that apply.)

Accepted Answer

Nurses can help the nation achieve the 2020 National Health Goals to reduce the number of diagnostic or therapeutic procedures for children by providing health counseling to both parent and child on ways to prevent children from becoming ill and subsequently requiring hospitalization, such as teaching sound nutrition and instructing on practices on avoiding unintentional injury. The goal is to reduce the number of diagnostic tests and not encourage them to be done annually. Focusing on the controversy with immunizations will not support the 2020 National Health Goals.

Question 4

The nurse is caring for an infant recovering from surgery for a cleft palate. Which type of restraint would be appropriate for the nurse to use when caring for this infant?

Accepted Answer

The elbow restraint is indicated to prevent children from touching the head or face after facial surgery. The jacket restraint is to restrain children younger than 6 months in a supine position. This will not prevent the baby from touching the face. The mummy restraint temporarily immobilizes young children for a procedure involving the head, neck, or throat. This might be the restraint used for the surgery but not for the postoperative care. The clove hitch restraint is used to secure one arm or leg for a procedure, such as an intravenous infusion.

Question 5

The nurse needs to assess the temperature of a 12-month-old infant. Which site should the nurse use for this assessment?

Accepted Answer

Thermometers that assess tympanic membrane temperature are ideal for assessment in children because they register within 2 seconds and therefore cause less fear because a child only has to be restrained for a few seconds. The axilla is the preferred site for temperature assessment for a newborn. The baby is too young to be able to keep an oral thermometer in the mouth. It is not necessary to use the rectum to measure the temperature on this child. This approach is too intrusive.

Question 6

The nurse is planning to instruct a school-age child on a barium swallow. What should the nurse do before beginning this instruction?

Accepted Answer

Before moving forward with preparation for a diagnostic test, the nurse needs to determine the child's knowledge about a test or similar tests. Pointing out a child's past experience with similar procedures can lay a foundation for increased cooperation. The parents do not necessarily have to participate in this teaching. Learning the time of the test can be done later. Checking the child's medical record will not help with the child's learning needs at this present time.

Question 7

What action should the nurse take after collecting a stool specimen for ova and parasites from a preschool-age child?

Accepted Answer

If a stool specimen is for ova and parasites, do not refrigerate it because refrigeration destroys the organisms to be analyzed. The specimen needs to arrive in the laboratory in less than 1 hour after collection so the parasites can be readily detected. Alcohol should not be added to the specimen container. The color of the stool sample is of no consequence.

Question 8

A nasogastric tube for enteral feedings has just been inserted in a 6-month-old infant. What should the nurse do to assess if the tube is in the patient's stomach?

Accepted Answer

It is necessary to use a syringe to aspirate the tube for any stomach residual before a feeding because it confirms the tube's placement in the stomach. Fluid should not be introduced through the nasogastric tube until placement has been confirmed. Listening for bowel sound and lowering the tube for drainage are not appropriate techniques to assess for nasogastric tube placement in an infant.

Question 9

A preschool-age child has not been able to eat for several days until all diagnostic tests are complete to determine the cause of chronic diarrhea. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time?

Accepted Answer

Because the child has not been able to eat for several days, the risk for imbalanced nutrition is high. This is the appropriate diagnosis for the nurse to select at this time. There is no enough information to determine if the child is at risk for injury, fearful of procedure rooms, or experiencing a deficiency in diversionary activities.

Question 10

The nurse instructs the mother of a toddler on the appropriate way to apply heat and cold to the child's ankle injury. Which statement indicates that instruction has been effective?

Accepted Answer

One guideline for the application of heat or cold is to supply a special activity for the child to enjoy while a hot or cold application is in place, such as reading a story or playing a game, so that the procedure is not viewed as a chore but as a pleasant time in which to look forward. Ice or heat should not be applied for longer than 20 minutes.
Pain medication can alter the perception of heat or cold, and the child could receive an injury from the application. To be certain that a heat application is not too hot, it should be tested with the inner wrist or the dorsal surface of the hand before applying it to the child.

Question 11

A 13-month-old child is having a dressing changed on a packed leg wound. Which action from the parents should be encouraged by the nurse during the treatment?

Accepted Answer

At the time of a procedure, the nurse should advocate for parents to be able to accompany their infant to hospital departments and remain during procedures to offer support. Some parents may ask to hold their child during a procedure that causes pain, but do not ask parents to restrain the child during such a procedure. Their role should be supportive and comforting and not one that causes pain. The father should be sitting next to the child. The father should be in the room with the child.

Question 12

Which process should the nurse use to assess the heart rate of a school-age child?

Accepted Answer

An apical pulse is taken in children younger than 1 year of age because their radial pulse is too faint to be palpated accurately. After 1 year of age, the radial pulse can be used and assessed for 1 minute. The femoral and brachial pulses are not used to determine heart rate of a school-age child.

Question 13

A school-age child is prescribed an enema in preparation for a colonoscopy. Which type of solution and amount should the nurse prepare for the child?

Accepted Answer

Normal saline is the usual solution for an enema for a child. For a school-age child, the amount of solution should be between 300 and 500 ml. Tap water is not used for an enema because it is not isotonic and can cause rapid shifts of fluids, leading to water intoxication. Milk of molasses is used to relieve a fecal impaction.

Question 14

The nurse is providing instructions to the parent of a school-age child who received conscious sedation for a bronchoscopy. What should the nurse include in this teaching? (Select all that apply.)

Accepted Answer

The nurse should instruct the parent to stay with the child for at least 4 hours to ensure dizziness does not occur with walking. The parent should also make sure that the child can swallow liquids without choking before providing solid food. If vomiting occurs, the health care provider should be contacted. The child's swallowing ability needs to be assessed before providing with solid food. Physical activity that requires alertness should be avoided for 12 hours because the sedation can affect coordination and balance.

Question 15

The nurse instructs the mother of a preschool-age child on the use of ibuprofen (Pediaprofen) prescribed for a temperature. Which statement indicates that the teaching has been effective?

Accepted Answer

Because ibuprofen (Pediaprofen) can cause gastrointestinal irritation, it should be given with food or fluids. The medication dosage should be measured by using the device supplied with the medication and not using a kitchen spoon. Fluids should be encouraged when taking this medication because renal failure can occur if the child becomes dehydrated. If the child complains of a stomachache while taking this medication, notify the health care provider. This could be an indication of an adverse effect.

Quiz 37: Nursing Care of a Family When a Child Needs Diagnostic or Therapeutic Modalities