Principles and Procedures for Nursing Care
of Children
1. What is the most appropriate statement for the nurse to make to a 5-year-old child who is
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undergoing a venipuncture?
a. "You must hold still or I'll have someone hold you down. This is not going to hurt."
b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast
and hurt less."
c. "Be a big boy and hold still. This will be over in just a second."
d. "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be
over soon."
ANS: B
The nurse can help minimize the pain and stress of the venipuncture by having someone help the
child maintain control during the procedure. Threatening the child with having someone hold
him or her down is likely to produce less cooperation and
frighten the child. Telling a child to be a "big boy" does not acknowledge the child's
developmental stage. Parents should be
allowed to stay during procedures when possible.
2. Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of
immunosuppression?
a. Spiritual distress
b. Social isolation
c. Deficient diversional activity
d. Sleep deprivation
ANS: C
Children in isolation need extra attention to avoid boredom. A 5-year-old child is not
developmentally advanced enough to feel
spiritual distress. The main social system for a 5-year-old child is the family, who should be
allowed liberal visitation. Sleep
deprivation may occur during hospitalization but is not specific to isolation.
3. What should the nurse consider when having consent forms signed for surgery and procedures
on children?
a. Only a parent or legal guardian can give consent.
b. The person giving consent must be at least 18 years old.
c. The risks and benefits of a procedure are part of the consent process.
d. A mental age of 7 years or older is required for a consent to be considered
"informed."
ANS: C
The informed consent must include the nature of the procedure, benefits and risks, and
alternatives to the procedure. In special
circumstances, such as emancipated minors, the consent can be given by someone younger than
18 years without the parent or
legal guardian. A mental age of 7 years is too young for consent to be informed.
4. The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures.
Guidelines for preparing this preschooler
should include
a. planning for a short teaching session of about 30 minutes.
b. telling the child that procedures are never a form of punishment.
c. keeping equipment out of the child's view.
d. using correct scientific and medical terminology in explanations.
ANS: B
Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly
that procedures are never a form of punishment. Teaching sessions for this age-group should be
much shorter in length. Demonstrate the use of equipment, and allow the child to play with
miniature or actual equipment. Explain the procedure in simple terms and how it affects the
child. [Show Less]