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Chapter 21: Family-Centered Care of the Child During Illness and Hospitalization

MULI!L" CH#IC"

1. A nurse is caring for four patients; three are toddlers and one is a preschooler. Whichrepresents the major stressor of hospitalization for these four patients?a. Separation anxiety

b. Loss of controlc. ear of bodily injuryd. ear of pain

A!S" A

#he major stressor for children from infancy through the preschool years is separation anxiety$

also called anaclitic depression. #his is a major stressor of hospitalization. Loss of control$

fear of bodily injury$ and fear of pain are all stressors associated %ith hospitalization.&o%e'er$ separation from family is a primary stressor in this age group.

(#S" 1 )*" +ogniti'e Le'el" Analyze ,-" 1/

#0(" *ntegrated (rocess" !ursing (rocess" -'aluation

S+" Area of +lient !eeds" &ealth (romotion and aintenance

2. )uring the first 3 days of hospitalization$ -ric$ age 14 months$ cried inconsolably %hen his parents left him$ and he refused the staff5s attention. !o% the nurse obser'es that -ric appears

to be 6settled in7 and unconcerned about seeing his parents. #he nurse should interpret this as

%hich statement?a. &e has successfully adjusted to the hospital en'ironment. b. &e has transferred his trust to the nursing staff.c. &e may be experiencing detachment$ %hich is the third stage of separation anxiety.d. 8ecause he is 6at home7 in the hospital no%$ seeing his mother fre9uently %ill only

start the cycle again.

A!S" +

)etachment is a beha'ior manifestation of separation anxiety. Superficially it appears that the

child has adjusted to the loss. )etachment is a sign of resignation$ not contentment. (arents

should be encouraged to be %ith their child. *f parents restrict 'isits$ they may begin a patternof misunderstanding the child5s cues and not meeting his needs.


#0(" *ntegrated (rocess" !ursing (rocess" )iagnosis


/. When a preschool child is hospitalized %ithout ade9uate preparation$ the nurse should

recognize that the child may li:ely see hospitalization as"a. punishment. b. threat to child5s selfimage.c. an opportunity for regression.d. loss of companionship %ith friends.

A!S" A

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*f a toddler is not prepared for hospitalization$ a typical preschooler fantasy is to attribute the

hospitalization to punishment for real or imagined misdeeds. Attributing the hospitalization to punishment for real or imagined misdeeds is a reaction typical of toddler and schoolage

children %hen threatened %ith loss of control.

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3. Which age group should the pediatric nurse recognize as being 'ulnerable to e'ents that lessen

their feeling of control and po%er?a. *nfants b. #oddlersc. (reschoolersd. Schoolage children

A!S" )

When a child is hospitalized$ the altered family role$ physical disability$ loss of peeracceptance$ lac: of producti'ity$ and inability to cope %ith stress usurp indi'idual po%er and

identity. #his is especially detrimental to schoolage children$ %ho are stri'ing for

independence and producti'ity and are no% experiencing e'ents that lessen their control and po%er. *nfants$ toddlers$ and preschoolers$ although affected to different extents by loss of

po%er$ are not as significantly affected as are schoolage children.




=. A 1>yearold girl needs to ha'e another intra'enous *@ line started. She :eeps telling the

nurse$ 6Wait a minute7 and 6*5m not ready.7 #he nurse should recognize this as %hich

description?a.

#his is normal beha'ior for a schoolage child. b. #he beha'ior is not seen past the preschool years.c. #he child thin:s the nurse is punishing her.d. #he child has successfully manipulated the nurse in the past.

A!S" A

#he 1>yearold girl is attempting to maintain control. #he nurse should pro'ide the girl %ithstructured choices about %hen the *@ %ill be inserted. #elling the nurse 6Wait a minute7 and

6*5m not ready7 can be characteristic beha'ior %hen an indi'idual needs to maintain some

control o'er a situation.

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#0(" *ntegrated (rocess" !ursing (rocess" *mplementationS+" Area of +lient !eeds" &ealth (romotion and aintenance

. #he most common initial reaction of parents to illness or injury and hospitalization in their

child is"a. anger. b. fear.c. depression.

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d. disbelief.

A!S" )

)isbelief is the most common initial response of parents. #his is especially true if the illness is

sudden and serious. Anger or guilt is usually the second reaction stage. ear$ anxiety$ andfrustrations also are common feelings. (arents may finally react %ith some form of depression

related to the physical and emotional exhaustion associated %ith a hospitalized child.

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#0(" *ntegrated (rocess" !ursing (rocess" AssessmentS+" Area of +lient !eeds" (sychosocial *ntegrity

B. Amy$ age years$ needs to be hospitalized again because of a chronic illness. #he clinic nurse

o'erhears her schoolage siblings tell her$ 6We are sic: of om al%ays sitting %ith you in the

hospital and playing %ith you. *t isn5t fair that you get e'erything and %e ha'e to stay %ith theneighbors.7 Which is the nurse5s best assessment of this situation?a. #he siblings are immature and probably spoiled. b. Cealousy and resentment are common reactions to the illness or hospitalization of a

sibling.c. amily has ineffecti'e coping mechanisms to deal %ith chronic illness.

d. #he siblings need to better understand their sister5s illness and needs.

A!S" 8

Siblings experience loneliness$ fear$ and %orry$ as %ell as anger$ resentment$ jealousy$ and

guilt. #he siblings experience stress e9ual to that of the hospitalized child. #here is noe'idence that the family has maladapti'e coping mechanisms.

(#S" 1 )*" +ogniti'e Le'el" Analyze ,-" 1B

#0(" *ntegrated (rocess" !ursing (rocess" Assessment

S+" Area of +lient !eeds" (sychosocial *ntegrity

4. An appropriate nursing inter'ention to minimize separation anxiety in a hospitalized toddler

%ould be to"a. pro'ide for pri'acy. b. encourage parents to room in.c. explain procedures and routines.d. encourage contact %ith children the same age.

A!S" 8

A toddler experiences separation anxiety secondary to being separated from the parents. #o

a'oid this$ the parents should be encouraged to room in as much as possible. aintainingroutines and ensuring pri'acy are helpful inter'entions$ but they %ould not substitute for the

parents. -ncouraging contact %ith children the same age %ould not substitute for ha'ing the

parents present.

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#0(" *ntegrated (rocess" !ursing (rocess" *mplementation


D. ouryearold 8rian appears to be upset by hospitalization. Which is an appropriate

inter'ention?a. Let him :no% it is all right to cry.

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b. Ei'e him time to gain control of himself.c. Sho% him ho% other children are cooperating.d. #ell him %hat a big boy he is to be so 9uiet.

A!S" A

+rying is an appropriate beha'ior for the upset preschooler. #he nurse pro'ides support

through physical presence. Ei'ing the child time to gain control is appropriate$ but the child

must :no% that crying is acceptable. #he preschooler does not engage in competiti'e

beha'iors.




1>. Latasha$ age 4 years$ is being admitted to the hospital from the emergency department %ith aninjury from falling off her bicycle. Which %ill help her most in her adjustment to the hospital?a. -xplain hospital schedules to her$ such as mealtimes. b. <se terms such as 6honey7 and 6dear7 to sho% a caring attitude.c. -xplain %hen parents can 'isit and %hy siblings cannot come to see her.d. 0rient her parents$ because she is young$ to her room and hospital facility.

A!S" A

Schoolage children need to ha'e control of their en'ironment. #he nurse should offer

explanations or prepare the child for those experiences that are una'ailable. #he nurse should

refer to the child by the preferred name. -xplaining %hen parents can 'isit and %hy siblingscannot come to see her is telling the child all of the limitations$ not helping her adjust to the

hospital. At the age of 4 years$ the child should be oriented to the en'ironment along %ith the

parents.




11. Samantha$ age = years$ tells the nurse that she 6needs a 8andAid7 %here she had an injection.

Which is the best nursing action?a. Apply a 8andAid. b. As: her %hy she %ants a 8andAid.c. -xplain %hy a 8andAid is not needed.d. Sho% her that the bleeding has already stopped.

A!S" A

+hildren at this age group still fear that their insides may lea: out at the injection site. (ro'ide

the 8andAid. !o explanation should be re9uired. #he nurse should be prepared to apply a

small 8andAid after the injection.

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S+" Area of +lient !eeds" &ealth (romotion and aintenance" Ero%th and )e'elopment

12. Fimberly$ age / years$ is being admitted for about 1 %ee: of hospitalization. &er parents tell

the nurse that they are going to buy her 6a lot of ne% toys$ because she %ill be in thehospital.7 #he nurse5s reply should be based on an understanding of %hich concept?

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a. !e% toys ma:e hospitalization easier. b. !e% toys are usually better than older ones for children of this age.c. At this age$ children often need the comfort and reassurance of familiar toys from

home.d. 8uying ne% toys for a hospitalized child is a maladapti'e %ay to cope %ith parental

guilt.

A!S" +

(arents should bring fa'orite items from home to be %ith the child. Goung children associateinanimate objects %ith people %ho are significant in their li'es. #he fa'orite items %ill

comfort and reassure the child. 8ecause the parents left the objects$ the preschooler :no%s the parents %ill return. !e% toys %ill not ser'e the purpose of familiar toys and objects from

home. #he parents may experience some guilt as a response to the hospitalization$ but there is

no e'idence that it is maladapti'e.




1/. atthe%$ age 14 months$ has just been admitted %ith croup. &is parent is tearful and tells the

nurse$ 6#his is all my fault. * should ha'e ta:en him to the doctor sooner so he %ouldn5t ha'eto be here.7 Which is appropriate in the care plan for this parent %ho is experiencing guilt?a. +larify misconception about the illness. b. -xplain to parent that the illness is not serious.c. -ncourage parent to maintain a sense of control.d. Assess further %hy parent has excessi'e guilt feelings.

A!S" A

Euilt is a common response of parents %hen a child is hospitalized. #hey may blame

themsel'es for the child5s illness or for not recognizing it soon enough. #he nurse should

clarify the nature of the problem and reassure parents that the child is being cared for. +roup is

a potentially serious illness. #he nurse should not minimize the parent5s feelings. *t %ould bedifficult for the parent to maintain a sense of control %hile the child is seriously ill. !o further

assessment is indicated at this time; guilt is a common response for parents.

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#0(" *ntegrated (rocess" !ursing (rocess" (lanning


13. A 13yearold boy is being admitted to the hospital for an appendectomy. Which roommate

should the nurse assign %ith this patient?a. A 3yearold boy %ith first day postappendectomy surgery b. A yearold boy %ith pneumonia

c. A 1=yearold boy admitted %ith a 'asoocclusi'e sic:le cell crisisd. A 12yearold boy %ith cellulitis

A!S" +

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When a child is admitted$ nurses follo% se'eral fairly uni'ersal admission procedures. #he

minimum considerations for room assignment are age$ sex$ and nature of the illness. Agegrouping is especially important for adolescents. #he 13yearold boy being admitted to the

unit after appendectomy surgery should be placed %ith a noninfectious child of the same sex

and age. #he 1=yearold child %ith sic:le cell is the best choice. #he 3yearold postappendectomy is too young$ and the child %ith pneumonia is too young and possibly has an

infectious process. #he 12yearold boy %ith cellulitis is the right age$ but he has an infection

cellulitis.

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S+" Area of +lient !eeds" Safe and -ffecti'e +are -n'ironment" anagement of +are

1=. #he nurse is caring for an adolescent %ho had an external fixator placed after suffering a

fracture of the %rist during a bicycle accident. Which statement by the adolescent should beexpected about separation anxiety?a. 6* %ish my parents could spend the night %ith me %hile * am in the hospital.7 b. 6* thin: * %ould li:e for my siblings to 'isit me but not my friends.7c. 6* hope my friends don5t forget about 'isiting me.7d.

6* %ill be embarrassed if my friends come to the hospital to 'isit.7A!S" +

Loss of peergroup contact may pose a se'ere emotional threat to an adolescent because of

loss of group status$ so friends 'isiting are an important aspect of hospitalization for anadolescent. ost adolescents do not need a parent to spend the night during hospitalization

and sometimes 'ie% the hospitalization as a %elcome e'ent. Adolescents %ould be more

concerned about friends 'isiting than siblings. Adolescents %ant 'isitors to :eep control and

maintain social status among their group of peers.

(#S" 1 )*" +ogniti'e Le'el" Analyze ,-" 1=



1. A nurse is preparing to complete an admission assessment on a 2yearold child. #he child issitting on the parent5s lap. Which techni9ue should the nurse implement to complete the

physical exam?a. As: the parent to place the child in the hospital crib. b. #a:e the child and parent to the exam room.c. (erform the exam %hile the child is on the parent5s lap.d. As: the child to stand by the parent %hile completing the exam.

A!S" +

#he nurse should complete the exam %hile the child is on the parent5s lap. or young children$

particularly infants and toddlers$ preser'ing parentIchild contact is the best means ofdecreasing the need for or stress of restraint. #he entire physical examination can be done in a parent5s lap %ith the parent hugging the child for procedures such as an otoscopic

examination. (lacing the child in the crib$ ta:ing the child to the exam room$ or as:ing the

child to stand by the parent %ould separate the child from the parent and cause anxiety.



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1B. A schoolage child$ admitted for intra'enous antibiotic therapy for osteomyelitis$ reports

difficulty in going to sleep at night. Which inter'ention should the nurse implement to assist

the child in going to sleep at bedtime?a. ,e9uest a prescription for a sleeping pill. b. Allo% the child to stay up late and sleep late in the morning.c. +reate a schedule similar to the one the child follo%s at home.

d. (lan passi'e acti'ities in the morning and interacti'e acti'ities right before bedtime.

A!S" +

any children obtain significantly less sleep in the hospital than at home; the primary causes

are a delay in sleep onset and early termination of sleep because of hospital routines. 0ne

techni9ue that can minimize the disruption in the child5s routine is establishing a dailyschedule . #his approach is most suitable for nonIcritically ill schoolage and adolescent

children %ho ha'e mastered the concept of time. *t in'ol'es scheduling the child5s day to

include all those acti'ities that are important to the child and nurse$ such as treatment procedures$ school%or:$ exercise$ tele'ision$ playroom$ and hobbies. #he schoolage child

%ith osteomyelitis %ould benefit from a schedule similar to the one follo%ed at home.

,e9uesting a prescription for a sleeping pill %ould be inappropriate and allo%ing the child tostay up late and sleep late %ould not be :eeping the child in a routine follo%ed at home.

(assi'e acti'ities in the morning and interacti'e acti'ities at bedtime should be re'ersed; it

%ould be better to :eep the child acti'e in the morning hours and plan 9uiet acti'ities at

bedtime.




14. A pre'iously 6pottytrained7 />monthold child has re'erted to %earing diapers %hile

hospitalized. #he nurse should reassure the parents that this is normal because of %hichreason?a. ,egression is seen during hospitalization. b. )e'elopmental delays occur because of the hospitalization.c. #he child is experiencing urinary urgency because of hospitalization.d. #he child %as too young to be 6pottytrained.7

A!S" A

,egression is expected and normal for all age groups %hen hospitalized. !urses should assure

the parents this is temporary and the child %ill return to the pre'iously mastered

de'elopmental milestone %hen bac: home. #his does not indicate a de'elopmental delay. #he

child should not be experiencing urinary urgency because of hospitalization and this %ouldnot be normal. Successful 6pottytraining7 can be started at 2 years of age if the child is ready.


#0(" *ntegrated (rocess" #eachingJLearning


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1D. A child is playing in the playroom. #he nurse needs to do a blood pressure on the child. Which

is the appropriate procedure for obtaining the blood pressure?a. #a:e the blood pressure in the playroom. b. As: the child to come to the exam room to obtain the blood pressure.c. As: the child to return to his or her room for the blood pressure$ then escort the

child bac: to the playroom.d. )ocument that the blood pressure %as not obtained because the child %as in the

playroom.

A!S" +

#he play room is a safe ha'en for children$ free from medical or nursing procedures. #he childcan be returned to his or her room for the blood pressure and then escorted bac: to the

playroom. #he exam room is reser'ed for painful procedures that should not be performed in

the child5s hospital bed. )ocumenting that the blood pressure %as not obtained because the

child %as in the playroom is inappropriate.




2>. A nurse in the emergency department is assessing a =yearold child %ith symptoms of pneumonia and a fe'er of 1>2K . Which inter'ention can the nurse implement to promote a

sense of control for the child?a. !one$ this is an emergency and the child should not participate in care. b. Allo% the child to hold the digital thermometer %hile ta:ing the child5s blood

pressure.c. As: the child if it is 0F to ta:e a temperature in the ear.d. &a'e parents %ait in the %aiting room.

A!S" 8

#he nurse should allo% the child to hold the digital thermometer %hile ta:ing the child5s

blood pressure. <nless an emergency is life threatening$ children need to participate in theircare to maintain a sense of control. 8ecause emergency departments are fre9uently hectic$

there is a tendency to rush through procedures to sa'e time. &o%e'er$ the extra fe% minutes

needed to allo% children to participate may sa'e many more minutes of useless resistance anduncooperati'eness during subse9uent procedures. #he child may not gi'e permission$ if as:ed$

for a procedure that is necessary to be performed. *t is better to gi'e choices such as$ 6Which

ear do you %ant me to do your temperature in?7 instead of$ 6+an * ta:e your temperature?7(arents should remain %ith their child to help %ith decreasing the child5s anxiety.

(#S" 1 )*" +ogniti'e Le'el" Apply ,-" /1



21. A nurse is admitting a toddler to the hospital. #he parent needs to lea'e for a brief period.Which figure depicts the reaction the nurse expects from the child?

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a. c.

b. d.

A!S" A

#he major stress from middle infancy throughout the preschool years$ especially for childrenages to /> months$ is separation anxiety$ also called anaclitic depression. )uring the stage

of protest$ children react aggressi'ely to the separation from the parent. #hey cry and scream

for their parents$ refuse the attention of anyone else$ and are inconsolable in their grief. Whenthe parent lea'es e'en for a short time this is the expected reaction and the figure that depicts

the child not %anting the parent to lea'e is %hat the nurse should expect as a reaction from the

child. #he child sitting alone sadly depicts a child in the despair stage. *n this stage depressionis e'ident. #he child is much less acti'e$ is uninterested in play or food$ and %ithdra%s from

others. #he child sitting on the parent5s lap is %ithdra%n and sad$ e'en in the presence of the parent. #he child depicted playing a game is adjusting to the hospitalization %ith play.


#0(" *ntegrated (rocess" !ursing (rocess" -'aluation


MULI!L" $"%!#&%"

1. A child has just been unexpectedly admitted to the intensi'e care unit after abdominal surgery.

#he nursing staff has completed the admission process$ and the child5s condition is beginningto stabilize. When spea:ing %ith the parents$ the nurses should expect %hich stressors to bee'ident? Select all that apply.a. <nfamiliar en'ironment b. <sual daynight routinec. Strange smellsd. (ro'ision of pri'acye. *nade9uate :no%ledge of condition and routine

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A!S" A$ +$ -

*ntensi'e care units$ especially %hen the family is unprepared for the admission$ are a strange

and unfamiliar place %ith many pieces of unfamiliar e9uipment. #he sights and sounds are

much different from those of a general hospital unit. Also$ %ith the child5s condition being

more precarious$ it may be difficult to :eep the parents updated and :no%ledgeable about%hat is happening. Lights are usually on around the cloc:$ seriously disrupting the diurnal

rhythm. #here is usually little pri'acy a'ailable for families in intensi'e care units.

(#S" 1 )*" +ogniti'e Le'el" <nderstand ,-" /2#0(" *ntegrated (rocess" !ursing (rocess" -'aluationS+" Area of +lient !eeds" (sychosocial *ntegrity

2. A nurse plans therapeutic play time for a hospitalized child. Which are the benefits of

therapeutic play? Select all that apply.a. Ser'es as method to assist disturbed children b. Allo%s the child to express feelingsc. #he nurse can gain insight into the child5s feelings.d. #he child can deal %ith concerns and feelings.e. Ei'es the child a structured play en'ironment

A!S" 8$ +$ )#herapeutic play is an effecti'e$ nondirecti'e modality for helping children deal %ith theirconcerns and fears$ and at the same time$ it often helps the nurse gain insights into children5s

needs and feelings. (lay and other expressi'e acti'ities pro'ide one of the best opportunities

for encouraging emotional expression$ including the safe release of anger and hostility. !ondirecti'e play that allo%s children freedom for expression can be tremendously

therapeutic. (lay therapy is a structured therapy that helps disturbed children. *t should not be

confused %ith therapeutic play.




/. A child is being discharged from an ambulatory care center after an inguinal hernia repair.

Which discharge inter'entions should the nurse implement? Select all that apply.a. )iscuss dietary restrictions. b. &old any analgesic medications until the child is home.c. Send a pain scale home %ith the family.d. Suggest the parents fill the prescriptions on the %ay home.e. )iscuss complications that may occur.

A!S" A$ +$ -

#he discharge inter'entions a nurse should implement %hen a child is being discharged from

an ambulatory care center should include dietary restrictions$ being 'ery specific and gi'ing

examples of 6clear fluids7 or %hat is meant by a 6full li9uid diet.7 #he nurse should gi'especific information on pain control and send a pain scale home %ith the family. All

complications that may occur after an inguinal hernia repair should be discussed %ith the

parents. #he pain medication$ as prescribed$ should be gi'en before the child lea'es the building and prescriptions should be filled and gi'en to the family before discharge.

(#S" 1 )*" +ogniti'e Le'el" Apply ,-" />

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#0(" *ntegrated (rocess" #eachingJLearning


3. A child is being admitted to the intensi'e care unit *+< and the parents are %ith the child.

Which creates stressors for children and parents in *+<s? Select all that apply.a. -9uipment noise b. (ri'acyc. +aring beha'ior by the nurse

d. <nfamiliar smellse. Sleep depri'ation

A!S" A$ )$ -

#he *+< can create physical and en'ironmental stressors for children and their families.

-9uipment noise monitors$ suction e9uipment$ telephones$ computers$ unfamiliar smells

alcohol$ adhesi'e remo'er$ body odors$ and sleep depri'ation all are stressors found in the*+<. (ri'acy as opposed to no pri'acy and a caring nurse as opposed to un:ind or thoughtless

comments from staff help reduce the stressors of the *+<.

(#S" 1 )*" +ogniti'e Le'el" <nderstand ,-" //



=. A nurse is inter'ie%ing the parents of a toddler about use of complementary or alternati'e

medical practices. #he parents share se'eral practices they use in their household. Which

should the nurse document as complementary or alternati'e medical practices? Select all thatapply.a. <se of acetaminophen #ylenol for fe'er b. Administration of chamomile tea at bedtimec. &ypnotherapy for relief of paind. Acupressure to relie'e headachese. +ool mist 'aporizer at the bedside for 6stuffiness7

A!S" 8$ +$ )

When conducting an assessment$ the nurse should in9uire about the use of complementary or

alternati'e medical practices. Administration of chamomile tea at bedtime$ hypnotherapy forrelief of pain$ and acupressure to relie'e headaches are complementary or alternati'e medical

practices. <sing #ylenol for fe'er relief and a cool mist 'aporizer at the bedside to reduce

6stuffiness7 are not considered complementary or alternati'e medical practices.

(#S" 1 )*" +ogniti'e Le'el" <nderstand ,-" 2>



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