Maternity and Pediatric Nursing 4th Edition Test Bank

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A nurse is admitting a toddler to the hospital. The toddler is with both parents and is currently sitting comfortably on a parent's lap. The parents state they will need to leave for a brief period. Which type of nursing diagnosis should the nurse formulate for this child?

  • A. Risk for anxiety
  • B. Anxiety
  • C. Readiness for enhanced coping
  • D. Ineffective coping
Correct Answer: A

Rationale: The appropriate nursing diagnosis for the toddler in this scenario would be "Risk for anxiety." The child is currently comfortable sitting on a parent's lap but may experience increased anxiety when the parents leave for a brief period. Since the parents' departure has not yet occurred and the child's reaction is uncertain, it is more appropriate to identify the potential risk of anxiety rather than stating the child is already experiencing anxiety. This diagnosis focuses on the potential for a negative emotion, providing an opportunity for nursing interventions to prevent or reduce anxiety in the child's upcoming situation.

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Which is descriptive of attention deficit hyperactivity disorder (ADHD)?

  • A. Manifestations exhibited are so bizarre that the diagnosis is fairly easy.
  • B. Manifestations affect every aspect of the child's life but are most obvious in the classroom.
  • C. Learning disabilities associated with ADHD eventually disappear when adulthood is reached.
  • D. Diagnosis of ADHD requires that all manifestations of the disorder be present.
Correct Answer: B

Rationale: Option B is descriptive of attention deficit hyperactivity disorder (ADHD). Manifestations of ADHD can significantly impact the child's life, but are most noticeable in the classroom setting. Children with ADHD may struggle with paying attention, staying organized, controlling impulsive behavior, and following instructions in the school environment. While symptoms can also affect other areas of life, such as social interactions and familial relationships, they are typically most prominently displayed in the structured school setting, making it easier to recognize and diagnose the disorder.

The MOST appropriate answer to why infants cry in response to another infant's cry is

  • A. an early sign of empathy development
  • B. a sign of good hearing reflex
  • C. a startle reflex
  • D. an early sign of fear development
Correct Answer: A

Rationale: Empathy begins developing early, though rudimentary.

What is the single most important factor to consider when communicating with children?

  • A. The child's physical condition
  • B. Presence or absence of the child's parent
  • C. The child's developmental level
  • D. The child's nonverbal behaviors
Correct Answer: C

Rationale: The single most important factor to consider when communicating with children is the child's developmental level. Understanding where a child is at in terms of cognitive, emotional, and social development is crucial for effective communication. By considering the child's developmental level, you can adjust your language, tone, and content to suit their abilities and needs. This ensures that the child can understand and engage with the communication effectively. Communication that aligns with a child's developmental stage promotes better comprehension, engagement, and relationship-building.

Which of the following tests would the nurse use as an initial screening test to determine hearing loss?

  • A. Romberg test
  • B. Caloric test
  • C. Otoscopic examination
  • D. Whisper voice test
Correct Answer: D

Rationale: The nurse would use the whisper voice test as an initial screening test to determine hearing loss. This test involves the nurse whispering a series of words or numbers from a distance behind the patient to assess their ability to hear and repeat the whispered words accurately. This test is quick, easy, and can be performed in a quiet environment without the need for special equipment, making it an effective initial screening tool for hearing loss. The Romberg test assesses balance, the caloric test evaluates vestibular function, and the otoscopic examination is used to assess the external ear canal and eardrum, but none of these tests specifically assess hearing loss.

In children with asthma, which of the following preoperative preparations is LEAST likely to be necessary?

  • A. Increase in beta-agonist dosage
  • B. Addition of systemic steroids
  • C. Bronchodilator therapy
  • D. None of the above
Correct Answer: D

Rationale: In stable asthmatic patients, additional interventions like systemic steroids or increased beta-agonist doses are not always necessary unless there are signs of exacerbation.

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