Maternal-Child McKinney Ch 34: Emergency Care of the Child

1. Which nursing action facilitates care being provided to a child in an emergency situation?

a. Encourage the family to remain in the waiting room.

b. Include parents as partners in providing care for the child.

c. Always reassure the child and family.

d. Give explanations using professional terminology.

ANS: B Include parents as partners in providing care for the child.

Include parents as partners in the child's treatments. Parents may need direct guidance in concrete terms to help distract the child. Allowing the parents to remain with the child may help calm the child. Telling the truth is the most important thing. False reassurance does not facilitate a trusting relationship. Professional terminology may not be understood. Speak to the child and family in language that they will understand.

2. The father of a child in the emergency department is yelling at the physician and nurses. Which action is contraindicated in this situation?

a. Provide a nondefensive response.

b. Encourage the father to talk about his feelings.

c. Speak in simple, short sentences.

d. Tell the father he must wait in the waiting room.

ANS: D Tell the father he must wait in the waiting room

Because a parent who is upset may be aggravated by observers, he should be directed to a quiet area. When dealing with parents who are upset, it is important not to be defensive or attempt to justify anyone's actions. Encouraging the father to talk about his feelings may assist him to acknowledge his emotions and may defuse his angry reaction. People who are upset need to be spoken to with simple words (no longer than five letters) and short sentences (no more than five words).

3. What is an appropriate nursing intervention for a 6-month-old infant in the emergency department?

a. Distract the infant with noise or bright lights.

b. Avoid warming the infant.

c. Remove any pacifiers from the baby.

d. Encourage the parent to hold the infant.

ANS: D Encourage the parent to hold the infant.

Parents should be encouraged to hold the infant as much as possible while in the emergency department. Having the parent hold the infant may help to calm the child. Distraction with noise or bright lights is most appropriate for a preschool-age child. In an emergency health care facility, it is important to keep infants warm. Infants use pacifiers to comfort themselves; therefore the pacifier should not be taken away.

4. Which action should the nurse working in the emergency department implement in order to decrease fear in a 2-year-old child?

a. Keep the child physically restrained during nursing care.

b. Allow the child to hold a favorite toy or blanket.

c. Direct the parents to remain outside the treatment room.

d. Let the child decide whether to sit up or lie down for procedures.

ANS: B Allow the child to hold a favorite toy or blanket.

Allowing a child this age to hold a favorite toy or blanket is comforting. It may be necessary to restrain the toddler for some nursing care or procedures. Because toddlers need autonomy and do not respond well to restrictions, the nurse should remove any restriction or restraint as soon as safety permits. Parents should remain with the child as much as possible to calm and reassure her. The toddler should not be given the overwhelming choice of deciding which position she prefers. In addition, the procedure itself may dictate the child's position.

5. Which nursing action is most appropriate to assist a preschool-age child in coping with the emergency department experience?

a. Explain procedures and give the child at least 1 hour to prepare.

b. Remind the child that she is a big girl.

c. Avoid the use of bandages.

d. Use positive terms, and avoid terms such as "shot" and "cut."

ANS: D Use positive terms, and avoid terms such as "shot" and "cut."

Using positive terms and avoiding words that have frightening connotations assist the child in coping. Preschool-age children should be told about procedures immediately before they are done. Allowing 1 hour of time to prepare only allows time for fantasies and increased anxiety. Children should not be shamed into cooperation. Bandages are important to preschool-age children. Children in this age-group believe that their insides can leak out and that bandages stop this from happening. Plus a fancy bandage can be used as a reward.

6. Which action should the nurse incorporate into a care plan for a 14-year-old child in the emergency department?

a. Limit the number of choices to be made by the adolescent.

b. Insist that parents remain with the adolescent.

c. Provide clear explanations, and encourage questions.

d. Give rewards for cooperation with procedures.

ANS: C Provide clear explanations, and encourage questions.

Adolescents are capable of abstract thinking and can understand explanations. They should be offered the opportunity to ask questions. Because adolescents are capable of abstract thinking, they should be allowed to make decisions about their care. Adolescents should have the choice of whether parents remain with them. They are very modest, and this modesty should be respected. Giving rewards such as stickers for cooperation with treatments or procedures is more appropriate for the younger child.

7. The emergency department nurse notices that the mother of a young child is making a lot of phone calls and getting advice from her friends about what she should do. This behavior is an indication of

a. stress.

b. healthy coping skills.

c. attention-getting behaviors.

d. low self-esteem.

ANS: A stress.

Hyperactive behavior such as making a lot of phone calls and enlisting everyone's opinions is a sign of stress. The behavior described is not a healthy coping skill. This may be an attention-getting behavior but is more likely an indicator of stress. This mother may have low self-esteem, but the immediate provocation is stress.

8. A preschool child in the emergency department has a respiratory rate of 10 breaths per minute. How should the nurse interpret this finding?

a. The child is relaxed.

b. Respiratory failure is likely.

c. This child is in respiratory distress.

d. The child's condition is improving.

ANS: B Respiratory failure is likely.

Very slow breathing in an ill child is an ominous sign, indicating respiratory failure. Although the respiratory rate slows when an individual is relaxed, a rate of 10 breaths per minute in an ill preschool child is not a normal finding and is cause for concern. A rapid respiratory rate indicates respiratory distress. Other signs of respiratory distress may include retractions, grunting, and nasal flaring. A respiratory rate of 10 breaths per minute is not a normal finding for a preschool child nor does it demonstrate improvement.{

10. What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg?

a. Alert the physician about the systolic blood pressure.

b. Comfort the child and assess respiratory rate.

c. Assess the child's responsiveness to the environment.

d. Alert the physician that the child may need intravenous fluids.

ANS: A  Alert the physician about the systolic blood pressure.

Hypotension is a late sign of shock in children. The lower limit for systolic blood pressure for a child more than 1 year old is 70 mm Hg plus two times the child's age in years. A systolic blood pressure of 58 mm Hg calls for immediate action. The nurse should be direct in relaying the child's condition to the physician. Comforting the child and assessing respiratory rate are not priorities. Assessing the child's responsiveness is included in a neurologic assessment. It does not address the systolic blood pressure of 58 mm Hg. Although this child most likely requires intravenous fluids, the physician must be apprised of the systolic blood pressure so that appropriate intervention can be initiated.

11. A nurse is caring for a child diagnosed with septic shock. He develops a dysrhythmia and hemodynamic instability. Endotracheal intubation is necessary. The physician feels that cardiac arrest may soon develop. What drug do you anticipate the physician will order?

a. Atropine sulfate

b. Epinephrine

c. Sodium bicarbonate

d. Inotropic agents

ANS: B Epinephrine

Epinephrine is the drug of choice for the management of cardiac arrest, dysrhythmias, and hemodynamic instability. Atropine sulfate is used to treat symptomatic bradycardia. Sodium bicarbonate is given to treat severe acidosis associated with cardiac arrest. Inotropic agents are indicated for hypotension or poor peripheral circulation in a child.

12. A nurse is working triage in the emergency department. A school-age child is brought in for treatment, carried by her mother. What assessment takes priority?

a. Assess airway patency.

b. Obtain a health history.

c. Obtain a full set of vital signs.

d. Evaluate for pain.

ANS: A Assess airway patency.

The primary assessment consists of assessing the child's airway, breathing, circulation, level of consciousness, and exposure (ABCDEs). Airway always comes first. History, vital signs, and pain assessment are all part of the secondary survey.

13. What is the goal of the initial intervention for a child in cardiopulmonary arrest?

a. Establishing a patent airway

b. Determining a pulse rate

c. Removing clothing

d. Reassuring the parents

ANS: A Establishing a patent airway

The first intervention for a child in cardiopulmonary arrest, as for an adult, is to establish a patent airway. Assessment of pulse follows establishment of a patent airway. Clothing may be removed from the upper body for chest compressions after a patent airway is established. Reassuring the parents is important, but the primary survey and associated interventions come first.

14. What is the nurse's immediate action when a child comes to the emergency department with sweating, chills, and fang bite marks on the thigh?

a. Secure antivenin therapy.

b. Apply a tourniquet to the leg.

c. Ambulate the child.

d. Reassure the child and parent.

ANS: A Secure antivenin therapy.

Antivenin therapy is essential to the child's survival because the child is showing signs of envenomation. The use of a tourniquet is no longer recommended. When a bite or envenomation is located on an extremity, the extremity should be immobilized in a dependent position. Envenomation is a potentially life-threatening condition. False reassurance is not helpful for building a trusting relationship.

15. How should the nurse instruct the mother who calls the emergency department because her 9-year-old child has just fallen on his face and one of his front teeth fell out?

a. Put the tooth back in the child's mouth and call the dentist right away.

b. Place the tooth in milk or water and go directly to the emergency department.

c. Gently place the tooth in a plastic zippered bag until she makes a dental appointment.

d. Clean the tooth and call the dentist for an immediate appointment.

ANS: B  Place the tooth in milk or water and go directly to the emergency department.

The parent should be told to keep the tooth moist by placing it in a saline solution, water, milk, or a commercial tooth-preserving solution and get the child evaluated as soon as possible. The parent may replace the tooth incorrectly, so it is best not to advise the parent to do this. The tooth should be kept moist, not dry. The child should be evaluated as soon as possible. Cleaning or scrubbing the tooth could damage it. It is essential for the child to have an immediate dental evaluation.

16. A 3-year-old is brought to the emergency department by ambulance after her body was found submerged in the family pool. The child has altered mental status and shallow respirations. She did not require resuscitative interventions. Which condition should the nurse monitor for as the priority in this child?

a. Neurologic status

b. Hypothermia

c. Hypoglycemia

d. Hypoxia

ANS: D Hypoxia

Hypoxia is responsible for the injury to organ systems during submersion injuries. Hypoxia can progress to cardiopulmonary arrest. Monitoring for hypoxia takes priority for this child over neurologic status, temperature, or glucose status.

17. Assessment of a child with a submersion injury focuses on which system?

a. Cardiovascular

b. Respiratory

c. Neurologic

d. Gastrointestinal

ANS: B Respiratory

Assessment of the child with a submersion injury focuses on the respiratory system. The airway and breathing are the priorities. The other systems are of less priority than the respiratory system.

18. Which is the most critical element of pediatric emergency care?

a. Airway management

b. Prevention of neurologic impairment

c. Maintaining adequate circulation

d. Supporting the child's family

ANS: A Airway management

Airway management is the most critical element in pediatric emergency care. The other elements are important, but airway is always the priority.

19. Which observations made by an emergency department nurse raises the suspicion that a 3-year-old child has been maltreated?

a. The parents are extremely calm in the emergency department.

b. The injury is unusual for a child of that age.

c. The child does not remember how he got hurt.

d. The child was doing something unsafe when the injury occurred.

ANS: B  The injury is unusual for a child of that age

An injury that is rarely found in children or is inconsistent with the age and condition of the child should raise suspicion of child maltreatment. The nurse should observe the parents' reaction to the child but must keep in mind that people behave very differently depending on culture, ethnicity, experience, and psychological makeup. The child may not remember what happened as a result of the injury itself, for example, sustaining a concussion. Also, a 3-year-old child may not be a reliable historian. The fact that the child was not supervised might be an area for health teaching. The nurse needs to gather more information to determine whether the parents have been negligent in the care of their child.

20. A child is brought to the emergency department after ingesting an acidic substance. What action by the nurse is best?

a. Induce vomiting in the child.

b. Give syrup of ipecac.

c. Ensure a patent airway.

d. Attach the child to a cardiac monitor.

ANS: C Ensure a patent airway.

Ensuring a patent airway is always the priority. Since the child ingested an acid that causes corrosive damage, inducing vomiting (which is what syrup of ipecac does) is not advised. The child may need a cardiac monitor, but airway is the priority.

21. Which initial assessment made by the triage nurse suggests that a child requires immediate intervention?

a. The child has thick yellow rhinorrhea.

b. The child has a frequent nonproductive cough.

c. The child's oxygen saturation is 95% by pulse oximeter.

d. The child is grunting.

ANS: D- The child is grunting.

One of the initial observations for triage is respiratory rate and effort. Grunting is a sign of hypoxemia and represents the body's attempt to improve oxygenation by generating positive end-expiratory pressure. Rhinorrhea, coughing, and a normal SaO2 do not need immediate intervention.

22. A child is brought to the emergency department. When he is called to triage, which vital sign should be measured first?

a. Temperature

b. Heart rate

c. Respiratory rate

d. Blood pressure

ANS: C Respiratory rate

When taking children's vital signs, the nurse observes the respiratory rate first. Temperature and blood pressure should be measured after respiratory and heart rate because it can be upsetting for children. Heart rate is measured after respiratory rate.

23. A 2-year-old child is in the playroom. The nurse observes him picking up a small toy and putting it in his mouth. The child begins to choke. He is unable to speak. Which intervention is appropriate?

a. Heimlich maneuver

b. Abdominal thrusts

c. Five back blows

d. Five chest thrusts

ANS: A Heimlich maneuver

To clear a foreign body from the airway, the American Heart Association recommends the Heimlich maneuver for a conscious child older than 1 year of age. Abdominal thrusts are indicated when the child is unconscious. Back blows are indicated for an infant with an obstructed airway. Chest thrusts follow back blows for the infant with an obstructed airway.

24. What condition does the nurse recognize as an early sign of distributive shock?

a. Hypotension

b. Skin warm and flushed

c. Oliguria

d. Cold, clammy skin

ANS: B Skin warm and flushed

An early sign of distributive shock is extremities that are warm to the touch. The child with distributive shock may have hypothermia or hyperthermia. Hypotension is a late sign of all types of shock. Oliguria is a manifestation of hypovolemic shock. Cold, clammy skin is a late sign of septic shock, which is a type of distributive shock.

25. What is the leading cause of unintentional death in children younger than 19 years of age in the United States?

a. Drowning

b. Airway obstruction

c. Pedestrian injury

d. Motor vehicle injuries

ANS: D Motor vehicle injuries

The Centers for Disease Control and Prevention (CDC) has consistently found that motor vehicle injuries are the leading cause of unintentional death in children younger than 19 years of age in the United States. Drowning, airway obstruction, and pedestrian injury do cause death but not at the rate of motor vehicle crashes.

26. A school-aged child develops heat exhaustion at a soccer game. What action by the nurse in attendance is best?

a. Call 911 immediately.

b. Move the child to a cooler environment.

c. Provide oxygen by face mask.

d. Prepare to begin CPR.

ANS: B Move the child to a cooler environment.

For simple heat exhaustion, treatment consists of moving the child to a cooler environment, apply cool, moist cloths to the skin; remove clothing or change to dry clothing; elevate legs; offer oral rehydration fluids if no altered mental status or vomiting. There is no need to call 911, provide oxygen, or prepare to begin CPR at this point.

27. A child has been brought to the emergency department with carbon monoxide poisoning. After the child is stabilized, what action by the nurse is best?

a. Have all family members tested for carbon monoxide poisoning.

b. Help family determine source of the carbon monoxide.

c. Prepare to administer syrup of ipecac.

d. Notify social services about the child's condition.

ANS: B Help family determine source of the carbon monoxide.

After the child has been stabilized, the nurse should help the family brainstorm about the source of the carbon monoxide poisoning, which must be eliminated before the child goes home. The nurse may need to offer assistance to find companies that can help in this search or notify the local fire department for assistance. There is no indication that other family members need to be tested, but those who show signs of carbon monoxide poisoning should be. Syrup of ipecac is no longer used after an oral ingestion. Social services may or may not need to be notified.

28. A 5 year-old child is in cardiopulmonary arrest, and the nursing staff is performing CPR. One of the nurses is doing compressions at the rate of 90 per minute. What action by the charge nurse is best?

a. Take over compressions.

b. Tell the nurse to speed up.

c. Tell the nurse to slow down.

d. Have the nurse compress more deeply.

ANS: B Tell the nurse to speed up.

The rate of compressions for a child is at least 100/minute. The charge nurse tells the compressing nurse to speed up. If the compressor is fatigued, someone should take over, but that is not indicated in the question. The depth of compressions is not the issue.

1. An emergency department nurse is making a general appearance assessment on a preschool child just admitted to the emergency department. Which general assessment findings indicate the child "looks bad"? (Select all that apply.)

a. Color pale

b. Capillary refill less than 2 seconds

c. Unwilling to separate from parents

d. Cold extremities

e. Lethargic

ANS: A, D, E Color pale, Cold extremities

Lethargic

Signs of a child "looking bad" on a general appearance assessment include pale skin, cold extremities, and lethargy. A capillary refill of less than 2 seconds is a "good sign" as well as a child who is unwilling to separate from parents (separation anxiety, expected).

2. What may cause hypovolemic shock in children? (Select all that apply.)

a. Hyperthermia

b. Burns

c. Vomiting or diarrhea

d. Hemorrhage

e. Skin abscesses

ANS: A, B, C, D Hyperthermia, Burns, Vomiting or diarrhea, Hemorrhage

Hypovolemic shock is due to decreased circulating volume and can be caused by fluid loss due to hyperthermia, burns, vomiting or diarrhea, and hemorrhage. An abscess will not cause hypovolemia.

30. The nurse observes abdominal breathing in a 2-year-old child. What does this finding indicate?

a. Imminent respiratory failure

b. Hypoxia

c. Normal respiration

d. Airway obstruction{

ANS: C

Young children normally exhibit abdominal breathing. When measuring respiratory rate, the nurse should observe the rise and fall of the abdomen. A very slow respiration rate is an indicator of respiratory failure. Nasal flaring with inspiration and grunting on expiration occurs when hypoxia is present. The child with an airway obstruction will use accessory muscles to breathe.

C-Normal respiration

ANS: C

Young children normally exhibit abdominal breathing. When measuring respiratory rate, the nurse should observe the rise and fall of the abdomen. A very slow respiration rate is an indicator of respiratory failure. Nasal flaring with inspiration and grunting on expiration occurs when hypoxia is present. The child with an airway obstruction will use accessory muscles to breathe.