Chapter 33 Child Health Nursing Partnering With Children & Families, 3rd Edition

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Chapter 33

Question 1

Type: MCSA

The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal?

1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft.

Correct Answer: 1

Rationale 1: The posterior fontanel closes between two and three months of age.

Rationale 2: Good head control is expected at four months of age.

Rationale 3: Rolling from abdomen to back is a skill the four-month-old should be learning.

Rationale 4: An open anterior fontanel, which is soft, is a normal finding at four months.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

 

Question 2

Type: MCSA

The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician’s order would the nurse question?

1. Passive range-of-motion exercises
2. Oxygen at 2L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neuro checks
4. Elevate head of bed 30 degrees

Correct Answer: 1

Rationale 1: Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible.

Rationale 2: Oxygen should be ordered to keep the child’s O₂ saturation above 95%.

Rationale 3: Hourly vital signs and neuro checks are appropriate to watch for changes in this child’s condition.

Rationale 4: The head is elevated 30 degrees to help decrease increased intracranial pressure.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-2

 

Question 3

Type: MCSA

A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include:

1. Appendicitis.
2. Bowel obstruction.
3. Urinary tract infection.
4. Kidney stones.

Correct Answer: 4

Rationale 1: Appendicitis does not occur as a result of the ketogenic diet.

Rationale 2: The ketogenic diet does not cause a bowel obstruction.

Rationale 3: Urinary tract infections are not a result of a ketogenic diet.

Rationale 4: Kidney stones are seen in 5% of children on a ketogenic diet.

Global Rationale:

 

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-3

 

Question 4

Type: MCSA

A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse’s initial action?

1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurological assessment.
4. Maintain patent airway.

Correct Answer: 4

Rationale 1: Taking vital signs is important, but airway always comes first.

Rationale 2: Once the airway is secure, securing an IV is vital.

Rationale 3: A rapid neurological assessment is appropriate once the airway is secure.

Rationale 4: Airway is always the priority of care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-3