Health Promotion 187

65. A mother has heard that several children 69. A parent brings a 5-year-old child to a vac-
have been diagnosed with mononucleosis. She cination clinic to prepare for school entry. The nurse
asks the nurse what precautions should be taken to notes that the child has not had any vaccinations
prevent this from occurring in her child. The nurse since 4 months of age. To determine the current
should instruct the mother to: evidence for best practices for scheduling missed
■ 1. Take no particular precautionary measures. vaccinations the nurse should:
■ 2. Sterilize the child’s eating utensils before they ■ 1. Ask the primary care provider.
are reused. ■ 2. Check the website at the Center for Disease
■ 3. Wash the child’s linens separately in hot, Control and Prevention (CDC).
soapy water. ■ 3. Read the vaccine manufacturer’s insert.
■ 4. Wear masks when providing direct personal ■ 4. Contact the pharmacist.
care.
70. A 13-month-old has a febrile seizure one
66. A father asks the nurse how he would know month after the administration of the chicken pox
if his child had developed mononucleosis. The vaccine. The nurse should:
nurse explains that in addition to fatigue, which of ■ 1. Recognize that the events are unrelated.
the following would be most common? ■ 2. Report the event through the Vaccine Adverse
■ 1. Liver tenderness. Event Reporting System.
■ 2. Enlarged lymph glands. ■ 3. Explain to the parents that this is a rare but
■ 3. Persistent nonproductive cough. acceptable risk.
■ 4. A blush-like generalized skin rash. ■ 4. Report the incident through the vaccine
manufacturer’s hotline.
67. A parent asks why it is recommended that
the second dose of the measles, mumps, and rubella 71. The school nurse is invited to attend a meet-
(MMR) vaccine be given at 4 to 6 years of age? The ing with several parents who express frustration
nurse should explain to the parent that the second with the amount of time their adolescents spend in
dose is given at this age for what reason? front of the mirror and the length of time it takes
■ 1. If the child reaches puberty and becomes them to get dressed. The nurse explains that this
pregnant when receiving the vaccine, the behavior indicates:
risks to the fetus are high. ■ 1. An abnormal narcissism.
■ 2. The chance of contracting the disease is much ■ 2. A method of procrastination.
lower at this age. ■ 3. A way of testing the parents’ limit-setting.
■ 3. The dangers associated with a strong reaction ■ 4. A result of developing self-concept.
to the vaccine are increased at this age.
■ 4. A serious complication from the vaccine is
swelling of the joints.
Answers, Rationales, and Test
Managing Care Quality and Safety Taking Strategies
68. An 18-year-old high school senior wishes to The answers and rationales for each question follow
obtain birth control through her parents’ insurance below, along with keys ( ) to the client need
but does not want the information disclosed. The (CN) and cognitive level (CL) for each question. Use
nurse tells the client that under the Health Informa- these keys to further develop your test-taking skills.
tion Portability and Accountability Act (HIPAA) For additional information about test-taking skills
parents: and strategies for answering questions, refer to pages
■ 1. Have the right to review a minor’s medical 10–21, and pages 25–26 in Part 1 of this book.
records until high school graduation.
■ 2. Have the right to review a minor’s medical
record if they are responsible for the payment. Health Promotion of the
■ 3. May not view the medical record, but may
Infant and Family
learn of the visit through the insurance bill.
■ 4. May not view the minor’s medical record or
the insurance bill.
1. 2. By trying to determine the source of
parents’ concerns, the nurse is able to acknowl-
edge their feelings and provide the most appro-
priate information. This approach increases the
likelihood parents will listen to the health care
provider’s views. Exemptions for vaccines vary by
state and many parents feel legal requirements for

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 188 The Nursing Care of Children

vaccinations take away parental rights. The number 6. 3. The posterior fontanel should be closed by
of vaccinations given at one time may not be the age 2 months. The anterior fontanel and sagittal and
issue. Waivers are used only if clients refuse vacci- frontal sutures should be closed by age 18 months.
nation after a discussion of risks and benefits.
CN: Health promotion and maintenance;
CN: Health promotion and maintenance; CL: Apply
CL: Synthesize
7. 4. Proper car seat placement for a child
2. 3. It is important for the nurse to assist par- younger than 1 year or weighing less than 20 lb is
ents in assessing speech development in their child facing the rear of the car. Without specialized train-
so that developmental delays can be identified early. ing, nurses may not understand how to correctly
According to the Denver Developmental Screening use all brands of car seats. Families who need help
Examination, at 8 months of age, the child should installing car seats should be referred to persons
say “mama” and “dada” nonspecifically and imi- who have had specialized training. The car seat is
tate speech sounds. A child cannot say “dada” or not in question and does not need to be replaced.
“mama” specifically or use more than three words Keeping the infant in an incorrect position while
until they are about 12 months of age. A child cannot completing the discharge reinforces the incor-
respond to specific commands or point to objects rect placement. The parents are unlikely to read a
when requested until about 17 months of age. manual, especially since the child is 8 months old
CN: Health promotion and maintenance; and it is very likely that they have been using this
CL: Apply position since birth. Additionally, the manual may
not be specific for their brand of car seat.
3. 4. According to the Denver Developmental
Screening Examination, a child of 8 months should CN: Safety and infection control;
sit without support for long periods of time. An CL: Synthesize
8-month-old child does not have the ability to stand 8. 3. By the end of 3 months infants should
without hanging on to a stationary object for sup- babble. Lack of babbling suggests a language delay
port. His muscles are not developed enough to sup- and warrants further investigation. Infants typically
port all his weight without assistance. His balance would begin playing peek-a-boo around 7 months.
has not developed to the point that he can stand and The ability to roll front to back typically occurs
stoop over to reach an object. at 5 months. Head lag is expected to resolve by
CN: Health promotion and maintenance; 5 months.
CL: Synthesize CN: Health promotion and maintenance;
4. 4. Infants should be kept on formula or breast CL: Analyze
milk until 1 year of age. The protein in cow’s milk 9. 3. Vaccination in the presence of a mod-
is harder to digest than that found in formula. The erate to severe infection, with or without fever,
infant cannot digest fats well, so some foods from the increases the risk of injury and decreases the chance
four food groups are not necessary in his diet during of mounting good immunity. There is currently no
infancy. Solids are introduced into the infant’s diet evidence to suggest vaccines raise the risk of SIDS.
around 4 to 6 months, after the extrusion reflex has A mild temperature may be expected with the DTaP.
diminished and when the child will accept new tex- A fever of greater than 40.5° within 48 hours of vac-
tures. Iron deficiency develops in term infants between cination would warrant caution. The DTaP is not
4 to 6 months when the prenatal iron stores are a live vaccine. No special precautions are needed
depleted. Fortified cereals can be added to the infant’s regarding immunosuppressed family members.
diet at 4 to 6 months to prevent iron deficiency anemia.
CN: Reduction of risk potential;
CN: Health promotion and maintenance; CL: Synthesize
CL: Create
10. 1. The American Academy of Pediatrics
5. 3. Understanding object permanence means recommends that infants who are delayed in receiv-
that the child is aware of the existence of objects ing their immunizations or have not started their
that are covered or displaced. Neuromuscular devel- series by 9 months of age begin with DTaP, Hib, IPV,
opment, curiosity, and the ability to transfer objects and PPD. OPV is not used because cases of polio
are not associated with the principle of object have been reported with use of the vaccine. MMR
permanence. Although, at 10 months, neuromuscu- and varicella vaccines are not administered until
lar development is sufficient to grasp objects and a 12 months of age.
child’s curiosity has increased, neither are related to
the thought process involved in object permanence. CN: Health promotion and maintenance;
CL: Synthesize
CN: Health promotion and maintenance;
CL: Apply

Billings_Part 2_Chap 2_Test 1.indd 188 8/7/2010 9:57:57 AM

 Health Promotion 189

11. 4. A 1-month-old infant is usually able to lift especially if there were other abnormal findings.
the head and turn it from side-to-side from a prone Closure of the anterior fontanel by 12 months can
position. The full-term infant with no complica- only be expected to occur in approximately a third
tions has probably been able to do this since birth. of all infants.
Smiling and laughing is expected behavior at 2 to CN: Health promotion and maintenance;
3 months. Rolling from back to side and holding a CL: Synthesize
rattle are characteristics of a 4-month-old.
16. 1. Normally, a 9-month-old infant should
CN: Health promotion and maintenance; have been voicing single syllables since 6 months
CL: Analyze of age. Absence of this finding would be a cause for
12. 3. The American Academy of Pediatrics concern. An infant usually is able to stand alone at
recommends that infants remain on iron fortified about 10 months of age. An infant usually is able
formula or breast milk until 1 year of age. The nurse to build a tower of two cubes at about 15 months of
needs to first assess if the mother switched the baby age. An infant usually is able to drink from a cup
prematurely to due to lack of information or lack with little spilling at about 15 months of age.
of resources. Then appropriate teaching or referrals CN: Health promotion and maintenance;
may be determined. At 1 year of age the infant may CL: Analyze
be switched to whole milk, which has a higher fat
content than 2%. The higher fat content is needed
for brain growth. Demanding clients change behav- Health Promotion of the Toddler
iors without addressing the cause is unlikely to
produce desired results. and Family
CN: Health promotion and maintenance; 17. 3. Behavior problems related to sleep and
CL: Analyze rest are common in young children. Consistent ritu-
13. 2. Holding the head erect when sitting, star- als around bedtime help to create an easier transi-
ing at an object placed in the hand, taking the object tion from waking to sleep. Allowing a child to sleep
to the mouth, cooing and gurgling, and sustaining with his parents commonly creates more problems
part of her body weight when in a standing position for the family and child and does not alleviate the
are behaviors characteristic of a 4-month old infant. problem or foster autonomy. Increasing activity
A 2-month-old typically vocalizes, follows objects to before bedtime does not alleviate the separation
the midline, and smiles. A 7-month-old typically is anxiety in the toddler and causes further anxiety.
able to sit without support, turns toward the voice, Allowing him to stay up later than his normal time
and transfers object from hand to hand. Usually, a for bed will increase his anxiety, make it more diffi-
9-month-old can crawl, stand while holding on, and cult for him to fall asleep, and do nothing to lessen
initiate speech sounds. his fear.

CN: Health promotion and maintenance; CN: Psychosocial adaptation;

CL: Analyze CL: Synthesize

14. 3, 6. Typical abilities demonstrated by 18. 4. Toddlers establish ritualistic patterns to

8-month-old infants include playing peek-a-boo and feel secure, despite inconsistencies in their envi-
transferring objects from one hand to another. The ronment. Establishing a sense of identity is the
ability to say “dada” and “mama” is more typical developmental task of the adolescent. The tod-
of 10-month-old infants. Infants usually are at least dler’s developmental task is to use rituals and rou-
12 months old when they achieve the ability to walk tines to help in making autonomy easier to accom-
independently. Infants who are 15 months old com- plish. Ritualistic patterns do involve patterns
monly can feed themselves with a spoon and stack of behavior but they are not utilized to develop
two blocks. learning behaviors.

CN: Health promotion and maintenance; CN: Psychosocial adaptation; CL: Apply
CL: Analyze 19. 1, 3, 4. Readiness for toilet training is based
15. 4. The anterior fontanel, commonly known on neurological, psychological, and physical
as the soft spot, closes between 12 to 18 months developmental readiness. The nurse can introduce
in most infants. The nurse normally measures an concepts of readiness for toilet training and encour-
infant’s occipital frontal circumference at each age parents to look for adaptive and psychomo-
well-child visit. This action alone does not relieve tor signs such as the ability to walk well, balance,
the parent’s concerns. Referrals would be indicated climb, sit in a chair, dress oneself, please the parent,
for premature or delayed closures of the fontanel and communicate awareness of the need to urinate
or defecate. Chronological age is not an indicator

Billings_Part 2_Chap 2_Test 1.indd 189 8/7/2010 9:57:57 AM

 190 The Nursing Care of Children

for toilet training. Two-year-olds engage in parallel 24. 2. Parents can be asked to assist when their
play, which is not an indicator of readiness for toilet child becomes uncooperative during a procedure.
training. Most commonly, the child’s difficulty in cooperating
CN: Health promotion and maintenance; is caused by fear. In most situations, the child will
CL: Apply feel more secure with a parent present. Other meth-
ods, such as asking another nurse to assist or wait-
20. 3. A child will regress to a behavior used ing until the child calms down, may be necessary,
in an earlier stage of development in order to cope but obtaining a parent’s assistance is the recom-
with a perceived threatening situation. Readiness mended first action. Restraints should be used only
for toilet training should be based on neurologi- as a last resort, after all other attempts have been
cal, physical, and psychological development, not made to encourage cooperation.
the age of the child. Children are afraid of hospi-
talization but the bedwetting is a compensatory CN: Health promotion and maintenance;
mechanism done to regress to a previous stage of CL: Synthesize
development that is more comfortable and secure 25. 4. In a child younger than 3 years of age, the
for the child. Telling the mother that bedwetting is pinna is pulled back and down, because the audi-
related to fluid intake does not provide an adequate tory canals are almost straight in children. In an
explanation for the underlying regression to an ear- adult, the pinna is pulled up and backward because
lier stage of development. the auditory canals are directed inward, forward,
CN: Psychosocial adaptation; and down.
CL: Synthesize CN: Pharmacological and parenteral
21. 4. Identifying ways to prevent difficulties in therapies; CL: Evaluate
parenting would be helpful in reducing the inci- 26. 4. Time out is the most appropriate discipline
dence of child abuse and reducing the stress of child for toddlers. It helps to remove them from the situa-
rearing. However, it would not help to develop tion and allows them to regain control. Structuring
positive attachment behaviors. Providing opportuni- interactions with 3-year-olds helps minimize unac-
ties for the mother to hold and examine the new- ceptable behavior. This approach involves setting
born and help with care helps establish a positive clear and reasonable rules and calling attention to
emotional bond between the mother and newborn. unacceptable behavior as soon as it occurs. Physical
Providing time for the mother to be alone with the punishment, such as spanking, does cause a dra-
infant further allows the mother and newborn to matic decrease in a behavior but has serious negative
bond. effects. However, slapping a child’s hand is effective
CN: Psychosocial adaptation; when the child refuses to listen to verbal commands.
CL: Synthesize Reasoning is more appropriate for older children,
such as preschoolers and those older, especially
22. 3. A craving to eat nonfood substances is when moral issues are involved. Unfortunately, rea-
known as pica. Toddlers use oral gratification as a soning combined with scolding often takes the form
means to cope with anxiety. Therefore, the nurse of shame or criticism and children take such remarks
should first assess whether the child is experienc- seriously, believing that they are “bad.”
ing any change in the home environment that could
cause anxiety. Teething or the eruption of large CN: Health promotion and maintenance;
teeth and the amount of attention from the mother CL: Synthesize
are unlikely causes of pica. Nutritional deficien- 27. 2. Toddlers usually express pain through
cies, especially iron deficiency, were once thought such behaviors as restlessness, facial grimaces,
to cause pica, but research has not substantiated irritability, and crying. It is not particularly help-
this theory. A soft, low-roughage diet is an unlikely ful to ask toddlers about pain. In most instances,
cause. they would be unable to understand or describe
CN: Physiological adaptation; the nature and location of their pain because of
CL: Analyze their lack of verbal and cognitive skills. However,
preschool and older children have the verbal and
23. 3. A 2-year-old child usually can kick a cognitive skills to be able to respond appropriately.
ball forward. Riding a tricycle is characteristic of a Numeric pain scales are more appropriate for chil-
3-year-old child. Tying shoelaces is a behavior to be dren who are of school age or older. Changes in vital
expected of a 5-year-old child. Using blunt scissors signs do occur as a result of pain, but behavioral
is characteristic of a 3-year-old child. changes usually are noticed first.
CN: Health promotion and maintenance; CN: Physiological adaptation;
CL: Analyze CL: Analyze

Billings_Part 2_Chap 2_Test 1.indd 190 8/7/2010 9:57:58 AM

 Health Promotion 191

28. 2. Toddlers around the age of 15 months 32. 1, 3. Some parents find that putting the child
need 2 to 3 cups of milk per day to supply necessary in time-out until control is regained is very effective.
nutrients such as calcium. A daily intake of more Others find that ignoring the behaviors works just as
than 3 cups of milk may interfere with the ingestion well with their child. Both suggestions are appropri-
of other necessary nutrients. ate to include in the teaching plan. Sending the child
to his bedroom means the child is being punished
CN: Health promotion and maintenance;
for having a tantrum. Spanking the child is never an
CL: Apply
option. Attempting to reason with a child having a
temper tantrum does not work because the child is
out of control. A more appropriate time to discuss it
Health Promotion of the Preschooler with the child is when the child regains control.
and Family
CN: Health promotion and maintenance;
CL: Create
29. 3. At age 4, the child should be learning to
dress without supervision. A child will feel more 33. 3. Children younger than 7 years of age do
autonomous if allowed to try to take on tasks herself. not have the manual dexterity needed for tooth
Such attempts should be encouraged to increase self- brushing. Therefore, parents need to help with this
esteem. Allowing choices encourages the child’s capac- task until that time.
ity to control her behavior. Continued dependency
may cause the child to doubt her own abilities. Telling CN: Health promotion and maintenance;
the child that a combination of clothes is not appropri- CL: Evaluate
ate may cause the child to doubt her abilities. Feelings 34. 2. The preschool-age child does not have an
of guilt can develop from not being able to accomplish accurate concept of skin integrity and can view med-
what the child feels the adult expects of her. ical and surgical treatments as hostile invasions that
can destroy or damage the body. The child does not
CN: Health promotion and maintenance;
understand that exsanguinations will not occur from
CL: Synthesize
the injection site. Here, the child is verbalizing a fear
30. 2. Preschool-age children have been consistent with the developmental age. The child
described as powerhouses of gross motor activity would most likely verbalize concerns of not wanting
who seem to have endless energy. A limitation of another procedure or exhibit other symptoms associ-
their motor ability is that in moving as quickly as ated with pain if those were the underlying issues.
they do, they are not always able to judge distances, If control was the main issue, the child would try to
nor are they able to estimate the amount of strength control more than just the bandage removal.
and balance needed for activities. As a result, they
CN: Psychosocial adaptation;
have frequent mishaps. This level of activity typi-
CL: Analyze
cally is not associated with changes at home. How-
ever, if the behavior intensifies, a referral to a pediat- 35. 3. Family changes and stresses (e.g., moving,
ric neurologist would be appropriate. Children who having company, taking a vacation, adding a new
have been abused usually demonstrate withdrawn member) can distract parents and contribute to acci-
behaviors, not endless energy. dents. Only children typically receive more atten-
tion than those with siblings. Thus, the risk would
CN: Health promotion and maintenance;
be less. Families who live in the suburbs frequently
CL: Synthesize
are more affluent and, therefore, better able to main-
31. 2. Bedtime is often a problem with preschool- tain a home less conducive to accidents. A parent’s
ers. Recommendations for reducing conflicts at formal education is unrelated to accidents.
bedtime include establishing a set bedtime; having a
CN: Health promotion and maintenance;
dependable routine, such as story reading; and con-
CL: Synthesize
veying the expectation that the child will comply.
Allowing the child to stay up late one or two nights 36. 3. Preschool-age children may view illness as
interferes with establishing the needed bedtime ritu- punishment for their fantasies. At this age children do
als. Excitement, such as active play, just before bed- not have the cognitive ability to separate fantasies from
time should be avoided because it stimulates the child, reality and may expect to be punished for their “evil
making it difficult for the child to calm down and pre- thoughts.” Viewing illness as a necessary part of life
pare for sleep. Using food such as a cookie as a reward requires a higher level of cognition than preschoolers
if bedtime is pleasant should be avoided because it possess. This view is seen in children of middle school
places too much importance on food. Other rewards, age and older. Perceiving illness as a test of self-worth
such as stickers, could be used as an alternative. or as the will of God is more characteristic of adults.
CN: Health promotion and maintenance; CN: Health promotion and maintenance;
CL: Synthesize CL: Apply

Billings_Part 2_Chap 2_Test 1.indd 191 8/7/2010 9:57:59 AM

 192 The Nursing Care of Children

Health Promotion of the School-Age 42. 3. Snacks are necessary for school-age chil-
Child and Family dren because of their high energy level. School-age
children are in a stage of cognitive development
37. 1, 3, 4. Blood pressures percentiles for in which they can learn to categorize or classify
children are referenced by the age, sex, and height. and can also learn cause and effect. By preparing
Measurements at or above the 95th percentile are their own snacks, children can learn the basics of
considered indicative of hypertension. Weight and nutrition (such as what carbohydrates are and what
elevated BMI contributes to hypertension but are not happens when they are eaten). The mother and
used to define it. The OFC is not routinely measured child should make the decision about appropriate
in children over 2 years of age. foods together. School-age children learn to make
decisions based on information, not instinct. Some
CN: Health promotion and maintenance; knowledge of nutrition is needed to make appropri-
CL: Analyze ate choices.
38. 4. School-age children are concerned about CN: Health promotion and maintenance;
justice and fair play. They become upset when they CL: Synthesize
think someone is not playing fair. Physical affection
makes them embarrassed and uncomfortable. They 43. 1. The values of height and weight percen-
are concerned about others and are cooperative in tiles are usually similar for an individual child.
play and school. Measurements between the 5th and 95th percentiles
are considered normal. Marked discrepancies iden-
CN: Health promotion and maintenance; tify overweight or underweight children.
CL: Analyze
CN: Health promotion and maintenance;
39. 3. During the school-age years children learn CL: Analyze
to socialize with children of the same age. The “best
friend” stage, which occurs around age 9 or 10 years
of age, is important in providing a foundation for
Health Promotion of the Adolescent
self-esteem and later relationships. Thinking inde-
pendently, organizing, and planning are cognitive and Family
skills. Active play relates to motor skills.
44. 3. This figure indicates elevation of the
CN: Health promotion and maintenance; papilla, without breast buds, considered Stage 1
CL: Analyze and typical of a preadolescent. Figure 1 shows
40. 2. Children are capable of mastering the stage 2, breast bud enlargement; there is elevation
skills required for flossing when they reach 9 years of the breast and the diameter of the areola has
of age. At this age, many children are able to assume increased. Figure 2 shows stage 3, enlargement of
responsibility for personal hygiene. She is not too the breast and areola. Figure 4 shows stage 4, in
young to assume this responsibility and she should which there is projection of areola and papilla to
not have been expected to assume this responsibility form a secondary mound above the level of the
much earlier. It is not likely that she is exaggerating; breast.
this is an expected behavior at this age. CN: Physiological adaptation;
CN: Health promotion and maintenance; CL: Analyze
CL: Analyze 45. 1. Vaccines are preventative in nature and
41. 2. School-age children delight in riddles and ideally given before exposure. Focusing on the
jokes. Mastery of the ambiguities of language and benefits of cancer prevention is most appropriate,
of sentence structure allows the school-age child to as opposed to discussing with parents the poten-
manipulate words, and telling riddles and jokes is tial that their child may become sexually active
a way of practicing this skill. Children who suf- without their knowledge. It is true HPV is most
fer from inadequate attention from parents tend to common in adolescents and women in their late
demonstrate abnormal behavior. Peer influence is twenties, but parents still may not perceive that
less important to school-age children, and while the their child is at risk. Discussing the possibility of
child may learn the joke from a friend, he is telling exposure through assault raises fears and does not
the joke to master language. Watching television focus on prevention.
does not influence the extent of joke telling. CN: Health promotion and maintenance;
CN: Health promotion and maintenance; CL: Apply
CL: Analyze

Billings_Part 2_Chap 2_Test 1.indd 192 8/7/2010 9:57:59 AM

 Health Promotion 193

46. 50. 3. Information about why adolescents choose

to use alcohol or other drugs can be used to deter-
2. Breathe out through the mouth. mine whether they are becoming responsible users
or problem users. The senior students likely know
1. Inhale through an open mouth. the legal implications of drinking, and the nurse
will establish a more effective relationship with the
students by understanding motivations for use. The
4. Press the canister to release the medication.
type of alcohol and when and with whom they are
using it are not the first data to obtain when assess-
3. Hold the breath for 5 to 10 seconds. ing the situation.

When dispensing medication from an inhaler, the CN: Health promotion and maintenance;
client should first breathe out through the mouth. CL: Analyze
Next the client inhales through an open mouth and
then presses the canister to dispense the medica-
tion while continuing to inhale and holds the breath Common Childhood and Adolescent
for 5 to 10 seconds. The client can then exhale and Health Problems
breathe normally.
CN: Pharmacological and parenteral
51. 2. The recommended safety-seat arrange-
ment for infants up to 20 lb and less than 1 year old
therapies; CL: Apply
is rear-facing with shoulder restraints. The middle
47. 3. Meningococcal vaccine should be admin- of the back seat is considered the safest area of the
istered before the adolescent enters college because car. Burns are a major cause of childhood accidents,
outbreaks of this type of meningitis are likely when and using fire screens in front of fireplaces can
people live in close association, such as in college help prevent children from getting too close to a
dorms. DTaP, varicella, and PCV are given as boost- fire in a fireplace. Toys that contain loose parts or
ers or initial doses before the child enters preschool plastic eyes that can be swallowed or aspirated by
or kindergarten. small children should be avoided. Parents should
inspect all toys for these parts before giving one to
CN: Health promotion and maintenance;
a child. Poisonings are most commonly caused by
CL: Apply
improper storage of a toxic substance. Keeping toxic
48. 2. Relieving dysmenorrhea in adolescence is substances in a child-proof container in a locked
crucial for the female’s development of positive self- cabinet and continually observing the child’s activi-
identity, of which positive body image and sexual ties can prevent most poisonings.
identity are important components. Menstruation
should not be viewed as painful and debilitating. CN: Safety and infection control;
Positive peer relations and a sense of independence CL: Evaluate
would develop with a positive self-identity. Sense of 52. 3. Strabismus is diagnosed through observa-
autonomy, according to Erikson, is the developmen- tion and use of the corneal light reflex test. The cov-
tal task of toddlers that, if successfully mastered, er-uncover test will reveal movement of the affected
leads to a sense of self-control. eye when the unaffected eye is covered, indicating
abnormal fixation of the affected eye. The child
CN: Physiological adaptation; CL: Apply
should be referred to an ophthalmologist as soon
49. 3. The nurse should provide the adoles- as possible so that the correct vision in the affected
cent with information about toxic shock syndrome eye can be restored. It is never normal for one eye to
because of the identified relationship between tam- turn inward or outward even if the child is tired. If
pon use and the syndrome’s development. Addition- this condition is not corrected early, blindness can
ally, about 95% of cases of toxic shock syndrome result in the unaffected eye due to the brain sup-
occur during menses. Most adolescent females can pressing the double vision. Thus, telling the mother
use tampons safely if they change them frequently. to watch the child and call later with concerns is not
Using tampons is not related to menstrual flow or an appropriate response. The child will not grow
sexual activity. There is no need to refer the girl to out of this type of condition and may need surgery,
a gynecologist; a nurse can provide health teaching an eye patch, daily exercises, or a combination of
about tampon use. these interventions.
CN: Reduction of risk potential; CL: CN: Health promotion and maintenance;
Synthesize CL: Synthesize

Billings_Part 2_Chap 2_Test 1.indd 193 8/7/2010 9:58:00 AM

 194 The Nursing Care of Children

53. 3. Adolescent boys lag about 2 years behind 58. 4. Griseofulvin is an antifungal agent that
adolescent girls in growth. Most girls are 1 to 2 acts by binding to the keratin that is deposited in
inches taller than boys at the beginning of adoles- the skin, hair, and nails as they grow. This keratin
cence but tend to stop growing approximately 2 to 3 is then resistant to the fungus. But as the keratin is
years after menarche with the closure of the epiphy- normally shed, the fungus enters new, uninfected
seal lines of the long bones. cells unless drug therapy continues. Long-term
administration of griseofulvin does not prevent sen-
CN: Health promotion and maintenance;
sitivity or allergic reactions. As the body adjusts to
CL: Apply
a new substance over time, side effects are variable
54. 2. Parents need to discuss with their adoles- and do not necessarily decrease.
cent how they perceive his behavior and how they
CN: Pharmacological and parenteral
feel about it. Moodiness is characteristic of adoles-
therapies; CL: Apply
cents. The adolescent may have a reason for or not
be aware of his behavior. Restricting the adolescent’s 59. 2. The adult pinworm emerges from the rec-
activities will not change his mood or the way he tum and colon at night onto the perianal area to lay
responds to others. It may increase his unacceptable its eggs. Itching and scratching introduces the eggs
responses. Counseling may not be needed at this to the hands, from where they can easily reinfect the
time if the parents are open to communicating and child or infect others. Nightclothes and bed linens
listening to the adolescent. Talking to other parents can be sources of infection. The eggs can also be
may be of some help, but what is helpful to others transmitted by dust in the home. Although transmis-
may not be helpful to their child. sion through contaminated food and water supplies
is possible, it is rare. Contaminated animals can
CN: Health promotion and maintenance;
spread histoplasmosis and salmonella. The spread
CL: Synthesize
of infections by toilet seats has not been supported
55. 1. The most common characteristic of head by research.
lice infestation (pediculosis capitis) is severe itching.
CN: Physiological adaptation; CL: Apply
The head is the most common site of lice infestation.
If the child scratches, scaling may occur. Itching 60. 3. The care of a child with chickenpox
also occurs when lice infest other parts of the body. focuses primarily on preventing infection in the
Scratch marks are almost always found when lice lesions. The lesions cause severe itching, and
are present. Weeping on the scalp surface may be organisms are ordinarily introduced into the
an indication of an infection or other dermatologic lesion through scratching. Acid-base imbalance
condition. Hemorrhagic spots are not a symptom of rarely occurs with chickenpox. Malnutrition is
head lice, but may be caused by scratch marks. a chronic problem associated with the ingestion
of an inadequate diet over a long period. It is not
CN: Physiological adaptation;
associated with chickenpox. Secondary infection
CL: Analyze
in the lesions, not the respiratory tract, is most
56. 3. Lice are spread by close personal con- common.
tact and by contact with infested clothing, bed and
CN: Physiological adaptation;
bathroom linens, and combs and brushes. Lice are
CL: Synthesize
more common in school-age children than in adults
because of the close contact in school and the com- 61. 3. A child with 20/60 vision sees at 20 feet
mon practice of sharing possessions. Lice are not what those with 20/20 vision see at 60 feet. A visual
commonly spread by hand contact. There is no acuity of 20/200 is considered to be the boundary of
immunity conferred by having head lice. Adults can legal blindness.
have head lice, particularly if they come in close con-
CN: Physiological adaptation;
tact with their children’s infested clothing or linens.
CL: Analyze
CN: Physiological adaptation; CL: Apply
62. 1. Children who have temper tantrums
57. 3. Ringworm of the scalp is caused by a fun- should be ignored as long as they are safe. They
gus of the dermatophyte group of the species. Over- should not receive either positive or negative
exposure to the sun would result in sunburn. Mites, reinforcement to avoid perpetuating the behavior.
such as chiggers or ticks, produce bites on the skin, Temper tantrums are a toddler’s way of achieving
resulting in inflammation. An allergic reaction com- independence.
monly is manifested by hives, rash, or anaphylaxis.
CN: Health promotion and maintenance;
CN: Physiological adaptation; CL: Evaluate
CL: Evaluate

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 Health Promotion 195

63. 3. Although children may be influenced Managing Care Quality and Safety
by their peers and smell and appearance of foods
may be important, children are most likely to be 68. 3. Under HIPAA, 18-year-olds have the
influenced by the example and atmosphere pro- right to medical privacy and their medical records
vided by their parents. Coaxing and badgering a may not be disclosed to their parents without their
child to eat most likely will aggravate poor eating permission. However, the adolescent must be made
habits. aware of the fact that information is sent to third
party payers for the purpose of reimbursement.
CN: Health promotion and maintenance;
Those payers send the primary insurer, in this case
CL: Apply
the parent, a statement of benefits. HIPAA protects
64. 3. Girls experience the onset of adolescence the right to medical privacy of all 18-year-olds
about 1 to 2 years earlier than boys. The reason for regardless of their educational status. Even if parents
this is not understood. are responsible for payment, they may not view the
client’s chart without the consent of the adolescent.
CN: Health promotion and maintenance;
CL: Apply CN: Management of care; CL: Apply
65. 1. The cause of infectious mononucleosis is 69. 2. The CDC is the federal body that is ulti-
thought to be the Epstein-Barr virus. No precaution- mately responsible for vaccination recommenda-
ary measures are recommended for clients with tions for adults and children. A division of the CDC,
mononucleosis. The virus is believed to be spread the Advisory Committee on Immunization Practices,
only by direct intimate contact. reviews vaccination evidence and updates recom-
mendation on a yearly basis. The CDC publishes
CN: Physiological adaptation;
current vaccination catch-up schedules that are
CL: Synthesize
readily available on their website. The lack of vacci-
66. 2. Mononucleosis usually has an insidious nations is a strong indicator that the child probably
onset, with fatigue and the inability to maintain does not have a primary care provider. If consulted,
usual activity levels as the most common symptoms. the pharmacist would most likely have to review
The lymph nodes are typically enlarged, and the the CDC guidelines that are equally available to the
spleen also may be enlarged. Fever and a sore throat nurse. Reading the manufacturer’s inserts for multi-
often accompany mononucleosis. A persistent non- ple vaccines would be time consuming and synthe-
productive cough can follow an upper respiratory sis of the information could possibly lead to errors.
tract infection. A blush-like generalized skin rash is
CN: Management of care; CL: Apply
more characteristic of rubella.
CN: Physiological adaptation;
70. 2. Any unusual event that occurs after the
administration of a vaccination should be reported.
CL: Analyze
Reporting the incident through the Vaccine Adverse
67. 1. After receiving the MMR vaccine, the per- Event Reporting System (VAERS), a joint program
son develops a mild form of the disease, stimulating from the FDA and CDC, helps to identify any new
the body to develop immunity. Administration to safety concerns. A high fever, with or without a sei-
a pregnant adolescent early in pregnancy puts the zure, that occurs within 6 weeks of vaccination may
fetus at risk for deformity or spontaneous abor- have been caused by the vaccine. A febrile seizure
tion. Some authorities recommend withholding the is considered a moderate reaction that warrants cau-
immunization for rubella until after puberty because tion with future chicken pox vaccination. Reporting
a woman does not always know when she is preg- the incident to the manufacturer does not help build
nant and a fetus could be placed in jeopardy. How- the same body of knowledge as reporting the prob-
ever, the risk of contracting the disease is not lower lem through the national surveillance system.
at this age. There is no difference in the reaction to
CN: Safety and infection control;
the vaccine at this age or in an older child. Swell-
CL: Synthesize
ing of the joints is a rare complication of the rubella
vaccine. 71. 4. An adolescent’s body is undergoing rapid
changes. Adolescence is a time of integrating these
CN: Pharmacological and parenteral
rapidly occurring physical changes into the self-
therapies; CL: Apply
concept to achieve the developmental task of a posi-
tive self-identity. Thus, most adolescents spend much
time worrying about their personal appearance. This
behavior is not abnormal narcissism, a method of
procrastination, or a way of testing the parents’ limits.
CN: Health promotion and maintenance;
CL: Analyze

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