Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care for an infant with an inner ear infection. The nurse is aware that the condition has occurred multiple times in a 3-month period. Which comment by the parent indicates t...
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care for an infant with an inner ear infection. The nurse is aware
that the condition has occurred multiple times in a 3-month period. Which comment by
the parent indicates to the nurse that specific teaching is needed regarding the incidences
of infection?
a. “I now put her to bed with a bottle.”
b. “I clean her ears with cotton swabs.”
c. “She likes her ears submerged while bathing.”
d. “Her older brother brings colds home from school.”
ANS: A
Chapter: Chapter 12 Respiratory Disorders
Chapter Learning Objective: 2. Identify differences in the anatomy and physiology of
the pediatric and adult patient.
Page: 222
Heading: Upper Airway Infectious Disorders > Otitis Media
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Caring
Difficulty: Difficult
Feedback
A. This is correct. Eustachian tubes are shorter and more horizontal in children than
adults and are more prone for migration of substances in the mouth to the inner
ear, causing an inner ear infection. The migration of milk is enhanced by putting
an infant to bed with a bottle. The nurse will present teaching on this topic.
B. This is incorrect. The nurse will reinforce that cotton swabs should not be placed
in a child’s ear. However, the practice is less likely to be the cause of an inner
infection.
C. This is incorrect. Some infants do not mind having their ears submerged when in
a bath. This practice alone is not likely to be the cause of an inner infection.
D. This is incorrect. An infant may be susceptible to an upper respiratory infection
from an older sibling who attends school. However, the scenario does not present
other symptoms of a cold, such as a stuffy nose.
PTS: 1 CON: Caring
,2. The nurse in a pediatric clinic is performing assessments on multiple infants. Which
infant does the nurse recognize as being at greatest risk for a respiratory disorder?
a. The infant born at 36 weeks who exhibited respiratory problems at birth
b. The infant who was born at term and recently adopted from another country
c. The infant who sleeps all night, exhibits eczema, and has a family history of
asthma
d. The infant with recurrent sore throats and both pets and smokers in the house
ANS: D
Chapter: Chapter 12 Respiratory Disorders
Chapter Learning Objective: 3. Identify the clinical presentation and nursing care of
the pediatric patient with respiratory disorders.
Page: 218
Heading: Respiratory Disorders > General History
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment
Difficulty: Moderate
Feedback
A. This is incorrect. Without additional manifestations or information, the premature
infant who exhibited respiratory problems at birth is not the patient with the
greatest risk for respiratory disorders. The only risk factor is gestational age.
B. This is incorrect. The infant who was recently adopted from another country is at
risk for respiratory problems because of unknown environmental, physiologic,
and/or genetic influences. The only risk factor is being born in another country.
C. This is incorrect. The infant with eczema and a family history of asthma has two
risks for the development of a respiratory disorder. Sleeping all night is not a risk
factor.
D. This is correct. The infant with recurrent sore throats and exposure to
environmental irritants such as pets and smokers in the household is at greatest
risk for developing a respiratory disorder. This patient is recognized by the nurse
as having three risk factors.
PTS: 1 CON: Clinical Judgment
3. The nurse in an acute care pediatric facility is preparing to assume care of multiple
patients at the change of shift. Which patient will the nurse plan to assess first?
a. The toddler who exhibits clubbing of the fingertips
b. The preschooler with pneumonia who has poor skin turgor
c. The infant who can sleep only with the head of the bed elevated
d. The infant who prefers a tripod position instead of lying down
, ANS: D
Chapter: Chapter 12 Respiratory Disorders
Chapter Learning Objective: 3. Identify the clinical presentation and nursing care of
the pediatric patient with respiratory disorders.
Page: 219
Heading: Respiratory Disorders > Physical Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment
Difficulty: Moderate
Feedback
A. This is incorrect. A toddler may exhibit clubbing of the fingertips if diagnosed
with chronic hypoxia from a chronic respiratory disorder. The manifestation
occurs over a period of time and does not alone indicate a need for being
assessed first.
B. This is incorrect. The preschooler with pneumonia and poor skin turgor may be
dehydrated from mouth breathing, tachypnea, fever, and/or anorexia. Without
additional symptoms, this is not the patient the nurse will assess first.
C. This is incorrect. The infant who can sleep only with the head of the bed elevated
is not presently in distress. This patient does not need to be assessed first.
D. This is correct. When an infant prefers to sit in a tripod position, exhibits a jaw
thrust, or is insistent on sitting upright, the indications are relevant to air hunger
and oxygen deficiency. This is the patient the nurse will assess first.
PTS: 1 CON: Clinical Judgment
4. Parents bring a toddler who is 2-1/2 years old to the hospital because of observed
difficulty with breathing. In addition, they share that at bedtime the toddler has a barky
cough. The toddler is diagnosed with laryngotracheobronchitis, commonly referred to as
croup. Which assessment finding does the nurse expect related to the diagnosis?
a. Fever accompanied by a congested cough
b. Inspiratory stridor heard in the upper airway
c. Elevated temperature and diaphoresis
d. Snoring sounds throughout respirations
ANS: B
Chapter: Chapter 12 Respiratory Disorders
Chapter Learning Objective: 3. Identify the clinical presentation and nursing care of
the pediatric patient with respiratory disorders.
Page: 219
Heading: Respiratory Disorders > Auscultation
Integrated Processes: Nursing Process
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