NUR 417 Exam 1 Blueprint

Question 1

Compare the physiological differences between the very young and the older child in regard to pharmacodynamics. (1 Question)

A) Infant versus older child
B) Pathophysiologic differences in infant

Answer 1

A) Infants - decreased gastric emptying, irregular gastric emptying, increased feedings and intestinal motility. Low albumin, limited binding of drugs. BB Barrier is not fully developed until 1 year. Immature liver and immature renal function.

Older Child - Gastric pH equal to adult at age 2-3. Plasma proteins adult level by 1. More effective skin and BB barrier. Decreased BMR after age 2, lowered effects of drugs. Adult renal function by age 2.

B. Infants - Greater total body water (80%). Greater body surface area.

Question 2

Identify the variations in medication administration between infants/children and adults (1 Question)

A) Proper way to administer medication
B) Proper administration for age

Answer 2

A) Liquid meds - Suspensions must be shaken, elixirs do not. Do not use droppers, teaspoons, or paper cups as they are subject to errors. Crying child can easily aspirate on medications. Many pills can be crushed given in honey, applesauce, or ice cream (can’t be time release). Rectal administration necessary to control vomiting or when oral route contraindicated. Cut suppositories lengthwise when having to halve it.

B) Proper medication administration Infants - Vastus Lateralis for Intramuscular Injection. Grasps Lateralis and choose length half the distance between thumb and index finger (5/8 inch). Needle Gauge 25-27. Lessen pain by firmly but gently secure infants in position where they can relax the muscle being used. Clean site with alcohol, dry, and stretch skin taught. To minimize tissue displacement, shear, and discomfort insert needle at 90 degrees. Slightly withdraw plunger of syringe to check that it did not enter vein or artery. Inject medication slowly. resting palm firmly on leg to prevent disruption. Apply light pressure to area and cover with bandage. Comfort infants or toddlers after an injection (hold and rock them). Another preferred IM site is ventrogluteal, it is safe for children of all ages. It is free of major nerves and blood vessel. May administer subcutaneous or intradermal (ventral forearm, 10-15 degrees) injections to children.

Proper administration for older children and 18 months = deltoid, Subcutaneous, 45 degrees. Distract child.
Oral route preferred for children whenever possible. Be honest and tell them you are giving medication. Never pretend it is candy.

Ear, eye, nose medications to children similar to adults. Major difficulty is getting child’s cooperation. When administering child’s ear drops, to minimize discomfort, warms meds to room temp. Under 3, pull pinna down and straight back. Children older than 3, pinna pulled upward and back. Dropper through disposable ear speculum. Gentle massage of area anterior to ear to help drops enter ear canal. Optic medications - Child supine with head extended, ask him to look up, moist cotton ball wash eye from inner canthus to outer canthus in 1 stroke. Pull lower eyelid down, and rest other hand on child’s head. Apple to conjunctival sac rather than directly to eyeball. Nasal medications - hyperextend head over edge of pillow, remain this way for 1 minute after drops instilled.

Where do you insert liquid medicine in an infant or child’s mouth and why? Between the tongue and side of the child’s mouth.

Question 3

Calculate safe dose of medication based on the child’s weight (2 Questions)

A. Correct dose for weight
B. Minimum and maximum dose per kg
C. Maximum dose per kg/day

Answer 3

Step 1: Convert weight from pounds to kilograms. If the weight is in kg then you do not have to
do this step.
Formula: Weight (pounds) x 1 kg/2.2 pounds
Step 2: Calculate the average (or safe) daily dosage range in mg/day for this patient.
Information is found in pediatric medication books available on pediatric units.
Formula (low range): weight (kg) x low range (mg/kg/day)
Formula (high range): weight (kg) x high l range (mg/kg/day)
Step 3: Calculate the dosage administered over 24 hours.
Formula: Dose ordered (mg/dose) x frequency (hrs/dose) x 1 day/24 hrs
Step 4: Compare ordered dose/day with dosage range to determine safe dose for patient.
Formula: Compare step 3 vs. step 2

Question 4

Calculate rate of infusion (mL/hr) for IV bolus (1 Question)

Answer 4

Example: Medication comes in 20 mg/2 mL. Order is 15 mg. Recommend minimum dilution of 1 mg/2 mL. What would you set pump if administering over 15 minutes?

First determine total volume of fluid to be infused (ignore the info about what the medication coming in 20 mg/2 mL).
15 mg x 1 mg/2 mL = 30 mL.

Then, divide by 15 minutes and convert to hour.

30 mL/15 minutes x 60 minutes/1 hour = 120 mL/hr

Question 5

Identify important components of medication safety education that the nurse would give to parents (1 Question)

Answer 5

Model safe use of medicines. Take medicines without children watching. Lock cabinets containing harmful substances or medicine (out of site, out of reach). Child resistant closures on cabinets. Be sure each adult knows who is giving medicine to child. Store in original containers. Discard unused medications. Use measuring devices intended for medicine, not household teaspoons. Do not call medicine candy.

Question 6

Interpret the pediatric patient’s fall risk based on use of the Humpty Dumpty Scale (2 Questions)

A. Calculating score

Answer 6

Note: Total max score is 23, min score 7. Score of 7-11 is low risk of fall. Score of greater than 12 is high risk. Based on 7 items: age, gender, diagnosis, cognitive impairments, environmental factors, response to surgery/anesthesia, and medication usage.

Add up the scores for each category. For example case study #3 we did in class the fall risk score is: 2+2+1+1+2+3+1 = 12.
For example case study #4 in class: 3+2+1+3+2+3+1 = 15

Question 7

Using Humpty Dumpty Scale score to guide nursing care

A. Examine interventions to prevent falls in the pediatric population

Answer 7

Note: Total max score is 23, min score 7. Score of 7-11 is low risk of fall. Score of greater than 12 is high risk.

For Infants: Avoid walkers. Ensure furniture sturdy enough for child to pull self to standing position. Fence stairways at top and bottom. Dress in safe shoes.

For Children: Nonskid mats, rooms/passageways clear of toys or furniture, safety glass in doors/windows, gates on top and bottom of staircases, guardrails on upstairs windows, crib side rails to full height, restraints in high chairs/walkers, scattered rugs secured in place, patios in good repair.

night light, appropriate bed/crib for age and development, appropriate use of side rails, never turn back without a hand on the infant, keep the room clutter free, keep the bed free from choking hazards, educate parents/children on falls

Question 8

Identify emergency equipment that should be maintained in the environment when a pediatric patient is in the hospital

Answer 8

Oxygen, appropriate alarm limits, code sheet, suction, appropriate size bag and mask

Question 9

Analyze why infants and young children are more susceptible to unintentional ingestion

A. Physical development
B. Psychological development
C. Common items ingested

Answer 9

A. Physical development - They are closer to the ground. They absorb more through skin due to greater body surface area. Their sense of taste is not discriminating at this age.

B. Psychological development - They don’t know to move out of danger. They are curious (explore environment through oral experimentation), think magically, or have lack of understanding. They are developing autonomy and initiative which increase their curiosity and noncompliant behavior.

C. Common Items Ingested: Cosmetics and personal care products (deodorants, makeup, perfume, cologne, mouthwash), medications (acetaminophen, acetylsalicylic acid, ibuprofen, opioids), Household cleaning products (bleaches, laundry pods, disinfectants), plants (nontoxic GI irritants, oxalates), foreign bodies, toys, desiccants, thermometers, bubble blowing solutions.

Foreign Body Ingestion/Aspiration: assess respiratory status, level of consciousness, nasal drainage (unilateral), choking, gagging, wheezing, coughing (paroxysmal), stridor, hoarseness, cyanosis, ability to speak

Question 10

Identify antidotes for common substances/medications ingested by children

Answer 10

1. Acetaminophen toxic dose 150 mg/kg. Antidote is N-acetylcysteine.
2. Amitriptyline TCA (Elavil). Antidote is Sodium Bicarbonate.
3. Beta-Adrenergic Blockers and Calcium Channel Blockers. Antidote is Glucagon.
4. Oral hypoglycemics such as Glypizide or Chlorpropamide. Antidote is Octreotide.
5. Aspirin (Acetylsalicylic Acid). Antidote is Activated Charcoal.

Calcium Sodium EDTA - treats severe lead poisoning.
Naloxone - reverses opioid overdose.
Flumazenil - treats Benzodiazepine toxicity.

Question 11

Identify the signs, symptoms and treatment of anaphylaxis

A. Common signs and symptoms
B. Treatment of anaphylaxis

Answer 11

Anaphylaxis is due to an interaction of an allergen or hypersensitivity to foods, medications, blood products or venoms.

A. Common signs and symptoms - Histamine is released from mast cells causing vasodilation, bronchoconstriction, and increased capillary permeability. Rapid, weak pulse, skin rash, nausea, and vomiting. Cutaneous signs are followed by angioedema.

chest tightness, hoarseness, barky cough, dysphagia, dyspnea, wheezing cyanosis, loss of consciousness, severe bradycardia, hypotension, cardiac arrest
Cyanosis: blue is not good, not getting enough oxygen; circumoral cyanosis in kids; in kids of color, pull their lip down and look inside to see if they are blue

B. Treatment of anaphylaxis - Injection of epinephrine (0.01 mg/kg to 0.3 mg/kg) and follow-up trip to an emergency room.

Question 12

Choose developmentally appropriate approaches for the assessment and teaching of the pediatric patient who is at various ages and stages of development (4 Questions)

Answer 12

Infants - Primarily use and understand nonverbal communication (smile and coo when content and cry when distressed). They respond to firm, gently handling and quiet, calm speech.

Early Childhood - Younger than 5 years old and are egocentric. Focus the communication on the child. Tell them what they can do or how they will feel. Experiences of others are of no interest to them. They can use hands to communicate ideas without words. Use simple, direct, and concrete language.

School Age Children - 6 to 12 years old. Rely less on what they see, more on what they know. They want explanations and reasons but require no verification beyond that. They want to know why, how, and intent and purpose. For example, explain to them a procedure such as taking blood pressure by showing them how to squeeze bulb to push air into the cuff and make the arrow move. Encourage them to communicate their needs and voice their concerns.

Adolescence - Fluctuates between child and adult thinking and behavior. The nurse should adjust the course of interaction to meet the client’s needs of the moment. If with parent, give both client and parent opportunity to be included in the interview in an open and unbiased atmosphere. Privacy and confidentiality are of great importance. Demonstrate positive communication skills.

Question 13

Identify expected and abnormal vital signs in the pediatric client (4 Questions)
A. Impacts of abnormal vital signs on pediatric client

Answer 13

A) Heart Rate: Awake Beats per minute Heart Rate: Sleeping Beats per minute Respirations Breaths per minute Systolic Blood Pressure (mm Hg)
Neonate: Birth to 1 month 100-205/min 90 to 160/min 30 to 60/min Hypotension < 60
Infant
(1 month to 12 months) 100-180/min 90 to 160/min 30 to 53/min Hypotension < 70
Toddler
(1 year – 3 years) 98 to 140/min 80 to 120/min 22 to 37/min Hypotension < 70 + (2X age in years)
Preschooler
(3 years – 6 years) 80 to 120/min 65 to 100/min 20 to 28/min Hypotension < 70 + (2X age in years)
School Aged
(6 years – 12 years) 75 to 118/min 58 to 90/min 18 to 25/min Hypotension < 70 + (2X age in years)
Adolescent (> 12 years) 60 to 100/min 50 to 90/min 12 to 20/min Hypotension < 90

Looking at if the kid is getting to the point where they can’t compensate; which direction are the vital signs trending – up or down?
They are more prone to decompensation very quickly compared to adults
FEVER: HR increases due to an increase in basal metabolic rate
Children have higher oxygen demands; their vital signs are higher at baseline

Question 14

Apply the use of the Pediatric Assessment Triangle to use in the clinic or hospital setting (1 Question)

Answer 14

Pediatric Assessment Triangle: Appearance - Tone, interactiveness, consolability, look/gaze, speech/cry.
Work of breathing: Abnormal breath sounds, abnormal positioning, retractions, and nasal flaring.
Circulation to the skin - Pallor, mottling, and cyanosis.

Most important thing: go in the room and LOOK at your patient (ASSESS!!)
Children compensate until they DON’T: they do not know how to stop
If vital signs do not fall WNL: reassess, check the vitals again

Question 15

Compare the patterns of development and growth as related to the pediatric client (2 Questions)

Answer 15

Development is differentiated - Development from simple operations to more complex activities and functions, from broad patterns of behavior to more specific refined patterns.

Development is orderly and sequential - Client passes through stages and has a fixed, precise order. For example, children crawl before they creep, creep before they stand, and stand before they walk.

Development is unique - Exact timing of growth is not predictable. Each child grows in his or her own personal ways.

Development is directional - Directions or gradients that reflect the physical development and maturation of neuromuscular functions. Can be cephalocaudal or head-to-tail or proximodistal or near-to-far.

Development is paced - There are periods of accelerated growth and periods of decelerated growth. Not all areas of development progress at the same pace. Rapid growth before and after birth, slow growth during middle childhood, markedly increases at beginning of adolescence, and levels off in early adulthood.

There are sensitive periods - Times that the client is more susceptible to positive or negative influences.

Question 16

Apply expected developmental milestones when caring for infants and children at the following ages: 2 months, 4 mos, 6 mos, 9 mos, 12 mos, 18 mos, 2-5 years, school aged, and adolescents (3 Questions)

Answer 16

INFANT
level of understanding: inability to describe illness, inability to follow directions,

impact of hospitalization: stranger anxiety between 6-18 mon, expressions of discomfort due to inability to verbalize, sleep deprivation due to strange noises, anxiety due to unfamiliar environment and fear of unknown

-place infants whose parents are not in attendance close to nurses station so that their needs can be quickly met, provide consistency in assigning caregivers

TODDLER
level of understanding: inability to describe illness, poorly developed sense of body image and boundaries,does not understand need for therapeutic procedures, limited ability to follow directions

impact of hospitalization: separation anxiety, can harbor fears of bodily harm, might believe illness and hospitalization as punishment

-encourage parents to provide routine care for the child, such as changing diapers and feeding, encourage the child’s autonomy by offering appropriate choices, provide consistency in assigning caregivers

PRESCHOOLERS
-explain procedures using simple, clear language, avoid medical jargon and terms that can be misinterpreted, encourage independence by letting the child provide self-care. encourage the child to express feelings, validate the child’s fears and concerns, provide toys that allow for emotional expression, such as a pounding board to release feelings of protest, provide consistency in assigning caregivers, give choices when possible, such as “do you want your medicine in a cup or spoon?”, allow younger children to handle equipment if it is safe

SCHOOL-AGE
level of understanding: beginning awareness of body functioning, ability to describe pain, increasing ability to understand cause and effect

impact of hospitalization: fears loss of control, seeks info as a way to maintain a sense of control, can sense when not being told the truth, can experience stress related to separation from peers and regular routine

-provide factual information, encourage the child to express feelings, try to maintain a normal routine for long hospitalizations, including time for school work, encourage contact with peer group

ADOLESCENT
level of understanding: increase ability to understand cause and effect, perception of illness severity are based on the degree of body image changes

impact of hospitalization: develops body image disturbance, attempts to maintain composure bit is embarrassed about losing control, experiences feelings of isolation from peers, worries about outcome and impact on school/activities, might not adhere to treatments/medications regimen due to peer influence

-provide factual information, including the adolescent in the planning of care to relieve feelings of powerlessness and lack of control, encourage contact with peer group

Question 17

Differentiate the theoretical frameworks of Erikson and Piaget in order to plan nursing interventions for infants and children that are appropriate for the child’s developmental state. (5 Questions)

Answer 17

Erikson - Looks at how one develops psychosocially

Piaget - Looks at how one thinks

Question 18

Identify the concepts related to developmental theories (4 Questions)
A. Negativism
B. Animism
C. Object Permanence
D. Egocentricity

Answer 18

A. Negativism - Develops at Erikson Autonomy vs Shame and Doubt stage (12 to 36 months). Persistent negative response to requests. The word “no” become sole vocabulary.
B. Animism - Develops at Piaget preoperational stage (2 to 4 years). Everything is alive including inanimate objects. Attributing lifelike qualities to inanimate objects.
C. Object Permanence - Develops at Piaget sensorimotor stage (birth to 2 years). The realization that objects that leave the visual field still exist. Ex. Infants pursue objects they hid.
D. Egocentricity - Develops at Piaget preoperational stage (2 to 7 years). Inability to envision situations from perspectives other than one’s own.

5. Conservation: an object weighing the same will take up the same space

Question 19

Differentiate the different types of play observed in the pediatric client (1 question)

Answer 19

Content play (social-affective play, sense-pleasure play, skill play, unoccupied behavior, dramatic/pretend play, and games) involves primarily the physical aspects of play, although social relationships cannot be ignored. Follows simple to complex trend.

Social character play (onlooker play, solitary play, parallel play, associative play, cooperative play) involves collaborative interactions of peers during play.

Question 20

Incorporate knowledge of play and development into a plan of care for a hospitalized pediatric client (2 Questions)

Answer 20

Play is not optional in hospitalized pediatric clients; it is essential to children’s mental, emotional, & social well-being; engaging in play gives child sense of control
Play can be used for: diversion, expression of feelings, educating child about procedures, help deal with their concerns during hospitalization, needs to be appropriate for age, interests, and developmental/cognitive level

Question 21

Illustrate the pain scales used dependent on the chronological or developmental age of the child (1 Questions)

Answer 21

Behavioral Pain Scales:
1) FLACC - For 2 months to 7 years of age. Stands for measurements of Face (expression), legs, activity, cry, consolability on a value of 0 (none) to 2 (frequent or strong expressions)

2) COMFORT Scale - For unconscious and ventilated infants, children, and adolescents. Also for critically ill and young children with burns. This scale has eight indicators: alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension. Each indicator is scored from 0 (none) to 5 (most intense). Total score is 0 to 40. A score of 17 to 26 indicates adequate sedation and pain control.

Self-Reported Pain Scales:
1) Wong-Baker FACES Pain Rating Scale - For 3 year olds. Uses facial expressions, numbers, and words to describe pain. Face 0 is very happy or no pain, Face 2 is hurst a little, Face 4 is hurts a little more, Face 6 is hurst even more, Face 8 is hurst a whole lot, and Face 10 or crying is hurts worst.

2) Numeric Scale - For children 5 years of age as long as they can count and have some concepts of numbers and their relationships. Straight line with endpoints from either 0 to 5 or 1 to 10 (from no pain to the worst pain).

Question 22

Identify different ways that children manifest or cope with pain depending on their age and developmental stage (2 Questions)

Answer 22

Infants: Localized to generalized body response, loud crying, facial expression, physical resistance.
Young Children: Loud crying, screaming, verbal expression, thrashing arms/legs, lack of cooperation, clinging (to parents, nurses, etc), begin the behaviors in anticipation of pain.
School-Age Children: Same as young children during the painful episode but not in anticipation. Stalling behaviors to avoid pain. Muscular rigidity.
Adolescent: Less vocal and motor response. Mover verbal expression. Increase muscle tension and body control.

Question 23

Develop a plan of care for a child in acute pain that integrates pharmacologic interventions and developmentally appropriate non-pharmacologic therapies (1 Question)

Answer 23

Stages of pain management in children: Assess child’s pain, Select appropriate pain relieving interventions, implement interventions, evaluate effective of intervention

Assess and reassess pain frequently, DO NOT delay pain relief

• Utilize child life specialists to distract the child during painful procedures; do not perform painful procedures in safe places such as the child’s room
• children are often unmedicated due to the risk of respiratory depression & addiction
• children cope different than adults by sleeping, playing video games, watching TV; this does not mean that the child is not in pain, they just cope differently!

Nonpharmacological Pain Management Therapies:
• Distraction: utilize pet therapy and child life
• Relaxation techniques
• Guided imagery: ask child what their favorite place is; use with teenagers
• Cutaneous stimulation: put it above where you’re going to stick the IV in
• Nonnutritive sucking: sucrose (sugar) water
• Kangaroo care: skin to skin time with the baby; helps with premature babies
• Swaddling
Specific Strategies:
- blowing bubbles: this forces them to take a big breath in
- deep breathing: breathe in hold for 5 seconds then breathe out
- playing games or FaceTime with their friends depending on development
- behavioral contracting: going to work with older kids, not everybody
- Infants: rocking, swaying, swaddling, nonnutritive sucking
Topical Pain Relief Medications / Methods:
Eutectic Mixture of Local Anesthetics (EMLA)
• Reduce pain from dermatologic procedures -venous access, LP, immunizations and more
• Effective- at least 30 - 60 minutes
Topical Vapocoolant Spray
• Applied directly to the skin without open lesions
• Effective in 15 seconds
• J-tip Needle Free Injection System
• No needles, uses pressurized gas to propel medication through the skin and into
SQ
• Effective immediately
• Buzzy – topical stimulant
• Combination of cold & vibrations
• Effective immediately

Question 24

Identify potential physical signs of Suspected Non-Accidental Trauma (SNAT) in children (1 Question)

Answer 24

Bruising in non-mobile patient, bruising to pinna/neck/abdomen, circumferential burn, injuries, enuresis, lack of social smile, UTIs/STDs, bleeding from genitalia/anus/mouth.

Risk Factors: having an unrelated partner in the home (especially if the unrelated partner is male), lack of income, education, self-esteem, history of substance abuse, history of being abused (parent was abused), lack of a support system
Potential Signs:
• Vague explanations of injury
• Delay in seeking care
• Inconsistencies in story
• Inappropriate responses from child or caregiver
• Malnutrition
• Dull affect
• School absences
• Munchausen Syndrome by Proxy: a parent/caregiver falsely reports symptoms in a child that are vague (stomach pain, head pain); the child is hospitalized in order to give the parent attention; they intentionally harm their child medically; psychological disorder
• Bruising in a non-mobile patient: bruising that is not developmentally appropriate (2 thumb prints on the chest, 4 finger prints on the back: due to grabbing, shaking)
• Burn, circumferential: burns in the shape of a circle; also dipping burns
• Injuries
• Enuresis: night time bed wetting in a kid that should not be bed wetting
• Lack of social smile
• Attempted suicide
• UTIs/STDs
• Bleeding from genitalia, anus or mouth: sign of sexual abuse

Question 25

Identify components of palliative care for the pediatric client (1 Question)

Answer 25

Defined as active total care (body, mind, and spirit) with or without curative intent. Appropriate at any stage in a serious illness (chronic, complex, potentially life-limiting conditions). Provided to patients and families over time based on needs, not prognosis. Offered in all care settings (tertiary care facilities, community health centers, children’s homes, etc). Focused on what is most important to the patient, family, caregiver(s). Focused on symptom control, supportive care, quality of life rather than cure. Interdisciplinary, multidisciplinary.

Components related to loss, grief, and coping ability: relationships and support systems, culture, ethnicity and religious beliefs, past experiences with loss, socioeconomic status (being able to miss work, to afford a funeral)
Grief: anticipatory (families begin to anticipate that separation), complicated, parental, sibling (how are the parents and siblings dealing with their grief)
Psychosocial Needs:
• Time to play and be a child
• Someone to talk to about fears, anger
• May have depression and withdrawal
• Address spiritual needs
• Some need permission from loved ones to die
• Need to continue to set limits
• Reassure that they are not alone (Fink, Watson, & Adler, n.d.)

Question 26

Identify the role of the family and healthcare team in providing palliative care for the dying child (1 Question)

Answer 26

Parents should be included in the child’s care and should be asked how they would like the child to be told of his or her dying status. Healthcare team must provide honest and accurate information about the child’s illness and prognosis. They must provide an atmosphere of open communication (effective communication among patient, family, and health care team). The healthcare team must educate and empower and provide comfort measures to patient and family.

Question 27

Identify risk factors for populations of children for health inequity (1 Question)

Answer 27

For children under 3 years of age: Poverty (21%), Low socioeconomic status (44%)
For children of color: 3x more likely in poverty than caucasian children
Children in foster care, public institutions, immigrant/refugee families, homes with drug/alcohol/violence. Children who are homeless/living in shelters, disabled, LGBTQ+, or uninsured or no access to medical providers.