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Test Bank for Nursing Care of Children,

3rd Edition: Susan R. James


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3. In most states, adolescents who are not emancipated minors must have parental permission
before:
a. treatment for drug abuse.
b. treatment for sexually transmitted diseases (STDs).
c. obtaining birth control.
d. surgery.
ANS: D
An emancipated minor is a minor child who has the legal competence of an adult. Legal counsel
may be consulted to verify the status of the emancipated minor for consent purposes. Most states
allow minors to obtain treatment for drug or alcohol abuse and STDs and allow access to birth
control without parental consent.

DIF: Cognitive Level: Application REF: p. 12


OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment

4. A nurse is completing a clinical pathway for a child admitted to the hospital with pneumonia.
Which characteristic of a clinical pathway is correct?
a. Developed and implemented by nurses
b. Used primarily in the pediatric setting
c. Specific time lines for sequencing interventions
d. One of the steps in the nursing process
ANS: C
Clinical pathways measure outcomes of client care and are developed by multiple healthcare
professionals. Each pathway outlines specific time lines for sequencing interventions and reflects
interdisciplinary interventions. Clinical pathways are used in multiple settings and for clients
throughout the life span. The steps of the nursing process are assessment, diagnosis, planning,
implementation, and evaluation.

DIF: Cognitive Level: Comprehension REF: p. 6


OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment

5. When planning a parenting class, the nurse should explain that the leading cause of death in
children 1 to 4 years of age in the United States is:
a. premature birth.
b. congenital anomalies.
c. accidental death.
d. respiratory tract illness.
ANS: C
Accidents are the leading cause of death in children ages 1 to 19 years. Disorders of short gestation
and unspecified low birth weight make up one of the leading causes of death in neonates. One of
the leading causes of infant death after the first month of life is congenital anomalies. Respiratory
tract illnesses are a major cause of morbidity in children.

DIF: Cognitive Level: Application REF: p. 9


OBJ: Nursing Process Step: Implementation
MSC: Safe and Effective Care Environment
6. Which statement is true regarding the “quality assurance” or “incident” report?
a. The report assures the legal department that there is no problem.
b. Reports are a permanent part of the client’s chart.
c. The nurse’s notes should contain the following: “Incident report filed and copy
placed in chart.”
d. This report is a form of documentation of an event that may result in legal action.
ANS: D
An incident report is a warning to the legal department to be prepared for potential legal action; it
is not a part of the client’s chart or nurse documentation.

DIF: Cognitive Level: Knowledge REF: p. 14


OBJ: Nursing Process Step: Implementation
MSC: Safe and Effective Care Environment

7. Which client situation fails to meet the first requirement of informed consent?
a. The parent does not understand the physician’s explanations.
b. The physician gives the parent only a partial list of possible side effects and
complications.
c. No parent is available and the physician asks the adolescent to sign the consent form.
d. The infant’s teenage mother signs a consent form because her parent tells her to.
ANS: C
The first requirement of informed consent is that the person giving consent must be competent.
Minors are not allowed to give consent. An understanding of information, full disclosure, and
voluntary consent are requirements of informed consent, but none of these is the first
requirement.

DIF: Cognitive Level: Comprehension REF: p. 12


OBJ: Nursing Process Step: Implementation
MSC: Safe and Effective Care Environment

8. A nurse assigned to a child does not know how to perform a treatment that has been prescribed for
the child. What should the nurse’s first action be?
a. Delay the treatment until another nurse can do it.
b. Make the child’s parents aware of the situation.
c. Inform the nursing supervisor of the problem.
d. Arrange to have the child transferred to another unit.
ANS: C
If a nurse is not competent to perform a particular nursing task, the nurse must immediately
communicate this fact to the nursing supervisor or physician. The nurse could endanger the child
by delaying the intervention until another nurse is available. Telling the child’s parents would
most likely increase their anxiety and will not resolve the difficulty. Transfer to another unit
delays needed treatment and would create unnecessary disruption for the child and family.

DIF: Cognitive Level: Application REF: p. 11


OBJ: Nursing Process Step: Implementation
MSC: Safe and Effective Care Environment
9. A nurse is completing a care plan for a child and is finishing the assessment phase. Which activity
is not part of a nursing assessment?
a. Writing nursing diagnoses
b. Reviewing diagnostic reports
c. Collecting data
d. Setting priorities
ANS: D
Setting priorities is a part of planning. Writing nursing diagnoses, reviewing diagnostic reports, and
collecting data are parts of assessment.

DIF: Cognitive Level: Comprehension REF: p. 19


OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

10. Which patient outcome is stated correctly?


a. The child will administer his insulin injection before breakfast on 10/31.
b. The child will accept the diagnosis of type 1 diabetes mellitus before discharge.
c. The parents will understand how to determine the child’s daily insulin dosage.
d. The nurse will monitor blood glucose levels before meals and at bedtime.
ANS: A
The outcome is stated in client terms, with a measurable verb and a time frame for action. The
verb “accept” is difficult to measure. The goal of accepting a diagnosis before hospital discharge is
unrealistic. Outcomes should be stated in client terms. Nursing actions are determined after
outcomes are developed in the implementation phase of the nursing process.

DIF: Cognitive Level: Application REF: p. 20


OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment

MULTIPLE RESPONSE

1. A nurse is reviewing the nursing care plan for a hospitalized child. Which statements are
collaborative problems? Select all that apply.
a. Risk for injury
b. Potential complication of seizure disorder
c. Altered nutrition: Less than body requirements
d. Fluid volume deficit
e. Potential complication of respiratory acidosis
ANS: B, E
In addition to nursing diagnoses, which describe problems that respond to independent nursing
functions, nurses must also deal with problems that are beyond the scope of independent nursing
practice. These are sometimes termed collaborative problems—physiological complications that
usually occur in association with a specific pathological condition or treatment. The potential
complications of seizure disorder and respiratory acidosis are physiological complications that will
require physician collaboration to treat. Risk for injury, altered nutrition, and fluid volume deficit
will respond to independent nursing functions.

DIF: Cognitive Level: Application REF: p. 20


OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment
2. Which nursing activities do not meet the standard of care? Select all that apply.
a. Failure to notify a physician about a child’s worsening condition
b. Calling the supervisor about staffing concerns
c. Delegating assessment of a new admit to the Unlicensed Assistive Personnel (UAP)
d. Asking the Unlicensed Assistive Personnel (UAP) to take vital signs
e. Documenting that a physician was unavailable and the nursing supervisor was notified
ANS: A, C
A nurse who fails to notify a physician about a child’s worsening condition and delegating the
assessment of a new admit to a UAP do not meet the standard of care. Calling the supervisor about
staffing concerns, asking the UAP to take vital signs, and documenting that a physician could not
be reached and the nursing supervisor was notified all meet the standard of care.

DIF: Cognitive Level: Analysis REF: p. 11|p. 12|p. 14


OBJ: Nursing Process Step: Evaluation MSC: Safe and Effective Care Environment
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