TEST 3: The Child with Cardiovascular and Hematologic Health Problems

Question 1

The Client Undergoing a Cardiac Catheterization
1. The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours
ago finds the dressing and bed saturated with blood. The nurse should first:
1. Assess the vital signs.
2. Reinforce the dressing.
3. Apply pressure just above the catheter insertion site.
4. Notify the primary health care provider.

Answer 1

The Client Undergoing a Cardiac Catheterization
1. 3. Direct pressure is the first measure that should be used to control bleeding. Taking the vital
signs will not control the bleeding. This should be done while another person is being sent to notify
the primary health care provider. The dressing can be reinforced after the bleeding has been
contained.
CN: Reduction of risk potential; CL: Synthesize

Question 2

2. A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family, the
   nurse should:
3. Advise the family to bring the child to the hospital for a tour a week in advance.
4. Explain that the child will need a large bandage after the procedure.
5. Discourage bringing favorite toys that might become associated with pain.
6. Explain that the child may get up as soon as the vital signs are stable.

Answer 2

2. 2. The catheter insertion site will be covered with a bandage. This is important for preschool
      children to know as they are very concerned about bodily harm. The best time to prepare a preschool
      child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help
      decrease the child’s anxiety. To prevent bleeding, the child will be expected to keep the extremity
      straight for 4 to 6 hours after the procedure, either in bed or on the parent’s lap.
      CN: Psychosocial integrity; CL: Synthesize

Question 3

3. When teaching the parents of a child with a ventricular septal defect who is scheduled for a
   cardiac catheterization, the nurse explains that this procedure involves the use of which of the
   following?
4. Ultra-high-frequency sound waves.
5. Catheter placed in the right femoral vein.
6. Cutdown procedure to place a catheter.
7. General anesthesia.

Answer 3

3. 2. In children, cardiac catheterization usually involves a right-sided approach because septal
      defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral
      vein through a percutaneous puncture. Echocardiography involves the use of ultra-high-frequency
      sound waves. A cutdown procedure is rarely used. The catheterization is usually performed under
      local, not general, anesthesia with sedation.
      CN: Reduction of risk potential; CL: Apply

Question 4

4. When developing the discharge teaching plan for the parents of a child who has undergone a
   cardiac catheterization for ventricular septal defect, which of the following should the nurse expect to
   include?
5. Restriction of the child’s activities for the next 3 weeks.
6. Use of sponge baths until the stitches are removed.
7. Use of prophylactic antibiotics before receiving any dental work.
8. Maintenance of a pressure dressing until a return visit with the primary health care provider.

Answer 4

4. 3. Prophylactic antibiotics are suggested for children with heart defects before dental work is
      done to reduce the risk of bacterial infection. Typically, activities are not restricted after a cardiac
      catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary.
      Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is
      discharged.
      CN: Reduction of risk potential; CL: Create

Question 5

The Client with a Congenital Heart Defect
5. Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin
(Lanoxin) should include which of the following? Select all that apply.
1. Give the medication at regular intervals.
2. Mix the medication with a small volume of breast milk or formula.
3. Repeat the dose one time if the child vomits immediately after administration.
4. Notify the primary care provider of poor feeding or vomiting.
5. Make up any missed doses as soon as realized.
6. Notify the primary care provider if more than two consecutive doses are missed.

Answer 5

The Client with a Congenital Heart Defect
5. 1, 4, 6. To achieve optimal therapeutic levels, digoxin should be given at regular intervals
without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than
two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels. The
medication should not be mixed with any other fluid as refusal may result in inaccurate intake of the
medication. Taking make-up doses, or taking the medication at times other than scheduled, may
adversely affect serum levels.CN: Pharmacological and parenteral therapies; CL: Create

Question 6

6. An 18-month-old with a congenital heart defect is to receive digoxin (Lanoxin) twice a day.
   The nurse should instruct the parents about which of the following?
7. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.
8. Signs of toxicity include loss of appetite, vomiting, increased pulse, and visual disturbances.
9. Digoxin is absorbed better if taken with meals.
10. If the child vomits within 15 minutes of administration, the dosage should be repeated.

Answer 6

6. 1. Digoxin’s effect is to slow the rate of the electrical conduction through the heart and increase
      the strength of the heart’s contraction. Signs of toxicity include anorexia and decreased heart rate.
      Digoxin should be taken 1 hour before meals or 2 hours after meals in order to obtain better
      absorption of the drug. If the child vomits within 15 minutes of administration, the dose should not be
      repeated because it is not known how much of the medication has been absorbed.
      CN: Pharmacological and parenteral therapies; CL: Apply

Question 7

7. Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The
   nurse should notify the surgeon about which of the following clinical findings?
8. A urine output of 60 mL in 4 hours.
9. Strong peripheral pulses in all four extremities.
10. Fluctuations of fluid in the collection chamber of the chest drainage system.
11. Alterations in levels of consciousness.

Answer 7

7. 4. Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities,
      cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in
      level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg/h.
      Therefore 60 mL/4 h is satisfactory. Strong peripheral pulses indicate adequate cardiac output.
      Drainage from the chest tube should show fluctuation in the drainage compartment of the chest
      drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about
      the 3rd postoperative day, the fluctuation ceases indicating the lungs have fully expanded.
      CN: Physiological adaptation; CL: Synthesize

Question 8

8. A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a
   blood specimen is obtained. The child’s color becomes blue and the respiratory rate increases to 44
   breaths/min. Which of the following actions should the nurse do first?
9. Obtain a prescription for sedation for the child.
10. Assess for an irregular heart rate and rhythm.
11. Explain to the child that it will only hurt for a short time.
12. Place the child in a knee-to-chest position.

Answer 8

8. 4. The child is experiencing a tet or hypoxic episode. Therefore the nurse should place the
      child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower
      extremities and reduces the volume of blood being shunted through the interventricular septal defect
      and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the
      systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also
      increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-
      chest position in the crib, or the mother learns to put the infant over her shoulder while holding the
      child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may
      need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and
      rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the
      hypoxia.
      CN: Physiological adaptation; CL: Synthesize

Question 9

9. When teaching a preschool-age child how to perform coughing and deep-breathing exercises
   before corrective surgery for tetralogy of Fallot, which of the following teaching and learning
   principles should the nurse address first?
10. Organizing information to be taught in a logical sequence.
11. Arranging to use actual equipment for demonstrations.
12. Building the teaching on the child’s current level of knowledge.
13. Presenting the information in order from simplest to most complex.

Answer 9

9. 3. Before developing any teaching program for a child, the nurse’s first step is to assess the
      child to determine what is already known. Most older preschool children have some understanding of
      a condition present since birth. However, the child’s interest will soon be lost if familiar material is
      repeated too often. The nurse can then organize the information in a sequence, because there are
      several steps to be demonstrated. These exercises do not require the use of equipment. The nurse
      should judge the amount and complexity of the information to be provided, based on the child’s
      current knowledge and response to teaching.
      CN: Psychosocial integrity; CL: Synthesize

Question 10

10. When assessing a child after heart surgery to correct tetralogy of Fallot, which of the
    following should alert the nurse to suspect a low cardiac output?
11. Bounding pulses and mottled skin.
12. Altered level of consciousness and thready pulse.
13. Capillary refill of 2 seconds and blood pressure of 96/67 mm Hg.
14. Extremities warm to the touch and pale skin.

Answer 10

10. 2. With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would
       include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and decrease
       in level of consciousness.
       CN: Physiological adaptation; CL: Analyze

Question 11

11. Which of the following is the greatest priority for the therapeutic management of a child with
    congestive heart failure (CHF) caused by pulmonary stenosis?
12. Educating the family about the signs and symptoms of infection.
13. Administering enoxaparin (Lovenox) to improve left ventricular contractility.
14. Assessing heart rate and blood pressure every 2 hours.
15. Administrating furosemide (Lasix) to decrease systemic venous congestion.

Answer 11

11. 4. Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing
       accumulated fluid is a primary goal of treatment in right-sided CHF. Lasix is used to reduce venouscongestion. It is important to educate the family about signs and symptoms of CHF but treating the
       client’s CHF is the priority. Lovenox is an anticoagulant and will not help improve left ventricular
       contractility. It is important to assess vital signs frequently in the child with CHF but assessments do
       not treat the problem.
       CN: Physiological adaptation; CL: Apply

Question 12

12. An infant weighing 9 kg is in the pediatric intensive care unit following arterial switch
    surgery. In the past hour, the infant has had 16 mL of urine output. Which action should the nurse take?
13. Notify the primary health care provider immediately.
14. Record the urine output in the chart.
15. Administer a fluid bolus immediately.
16. Assess for other signs of hypervolemia.

Answer 12

12. 2. Urine output for an infant weighing 9 kg should be 1 mL/kg/h. 16 mL of urine output is more
       than adequate for 1 hour so the nurse should record the output in the chart. There is no reason to notify
       the primary health care provider regarding adequate urine output. The infant has adequate output so
       there is no need for a fluid bolus. A fluid bolus could also cause the infant to become fluid
       overloaded, increasing the workload on the heart. There is no information in the question indicating
       that the child is hypervolemic.
       CN: Physiological adaptation; CL: Analyze

Question 13

13. A child has had open heart surgery to repair a tetralogy of Fallot with a patch. The nurse
    should instruct the parents to:
14. Notify all health care providers before invasive procedures for the next 6 months.
15. Maintain adequate hydration of at least 10 glasses of water a day.
16. Provide for frequent rest periods and naps during the first 4 weeks.
17. Restrict the ingestion of bananas and citrus fruit.

Answer 13

13. 1. Children who have undergone open heart surgery with a patch are at risk for infection,
       especially subacute bacterial endocarditis (SBE), for the first 6 months following surgery. The
       newest evidence-based guidelines suggest that once the patch has epithelialized, these precautions are
       no longer necessary. Therefore, parents are instructed about SBE precautions including the need to
       notify providers before invasive procedures so antibiotics can be prescribed for that time period.
       Having the child drink a very large amount of water may lead to fluid overload. Children gear their
       rest schedule to their activities making it unnecessary to schedule frequent rest periods. Bananas and
       citrus fruit are high in potassium, but there is no evidence provided that the child has an elevated
       serum potassium requiring restriction.
       CN: Physiological adaptation; CL: Synthesize

Question 14

14. As part of the preoperative teaching for the family of a child undergoing a tetralogy of Fallot
    repair, the nurse tells the family upon returning to the pediatric floor that the child may:
15. Be placed on a reduced sodium diet.
16. Have an activity restriction for several days.
17. Be assigned to an isolation room.
18. Have visits limited to a select few.

Answer 14

14. 1. Because of the hemodynamic changes that occur with open heart surgery repair, particularly
       with septal defects, transient congestive heart failure may develop. Therefore, the child’s sodium
       intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically the
       child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any
       postoperative client, therefore isolation is not necessary. The child may be placed in a room with
       other children who are not contagious. Visitors are not restricted unless the pediatric unit has
       restrictive visiting policies.
       CN: Physiological adaptation; CL: Synthesize

Question 15

15. After surgery to correct a tetralogy of Fallot, the child’s parents express concern to the nurse
    that their 4-year-old child wants to be held more frequently than usual. The nurse recommends:
16. Introducing a new skill.
17. Play therapy.
18. Encouraging the behavior.
19. Having the volunteer hold the child.

Answer 15

15. 2. The child is exhibiting regression. During periods of stress, children frequently revert to
       behaviors that were comforting in earlier developmental stages; play therapy is one way to help the
       child cope with the stress. Teaching a new skill most likely would add more stress. Parents should be
       instructed to praise positive behaviors and ignore regressive behaviors rather than calling attention to
       them through encouragement or discouragement. Having someone else hold the child does not
       encourage coping with the stress or promoting appropriate development.
       CN: Psychosocial integrity; CL: Synthesize

Question 16

16. The mother of a child hospitalized with tetralogy of Fallot tells the nurse that the child’s 3-
    year-old sibling has become quiet and shy and demonstrates more than a usual amount of genital
    curiosity since this child’s hospitalization. The nurse should tell the mother:
17. “This behavior is very typical for a 3-year-old.”
18. “This may be how your child expresses feeling a need for attention.”
19. “This may be an indication that your child may have been sexually abused.”
20. “This may be a sign of depression in your child.”

Answer 16

16. 2. According to Erikson, the central psychosocial task of a preschooler is to develop a sense
       of industry versus guilt. Any environmental situation may affect the child. In this situation the sibling
       is probably feeling less attention from the mother and trying to resolve the conflict in an inappropriate
       way. Three-year-olds are usually active and outgoing. These behaviors represent a change. Data are
       not sufficient to suggest the child has been exposed to a sexual experience. Symptoms of depressionwould include withdrawal and fatigue.
       CN: Psychosocial integrity; CL: Synthesize

Question 17

The Client with Rheumatic Fever
17. A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He
has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is
experiencing aimless movements of his extremities. Use the chart below to determine what the nurse
should do first.
1. Report the heart rate to the primary health care provider.
2. Apply lotion to the rash.
3. Splint the joints to relieve the pain.
4. Request a prescription for medication to treat the elevated temperature.

Answer 17

17. 1. The child’s heart rate of 150 bpm is significantly above its rate at the time of his admission.
       The nurse must notify the primary health care provider. The increase in heart rate may indicate
       carditis, a possible complication of rheumatic fever that can cause serious and life-long effects on the
       heart. The primary health care provider will intervene with medication and cardiac monitoring.
       While lotion may soothe the itching, the most important action for the nurse is to notify the primary
       health care provider of the increased heart rate. Splinting will not help the inflammation that is
       causing the painful joints. The painful joints migrate and will subside with time. The temperature is
       not elevated at this time, and does not require intervention.
       CN: Physiological adaptation; CL: Synthesize

Question 18

18. A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the
    parents to:
19. Observe the child closely.
20. Allow the child to participate in activities that will not tire him.
21. Provide for adequate periods of rest between activities.
22. Encourage someone in the family to be with the child 24 hours a day.

Answer 18

18. 3. The nurse should teach the parents to provide for sufficient periods of rest to decrease the
       client’s cardiac workload. The client’s condition does not warrant close observation unless cardiac
       complications develop. The child’s activity level will be based on the results of the sedimentation
       rate, c-reactive protein, heart rate, and cardiac function. The family does not need to be with the
       client 24 hours a day unless carditis develops and his condition deteriorates.
       CN: Basic care and comfort; CL: Synthesize

Question 19

19. A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which statement
    by the client indicates that the nurse should notify the health care provider?
20. “I hear ringing in my ears.”
21. “I put lotion on my itchy skin.”
22. “My stomach hurts after I take that medicine.”
23. “These pills make me cough.”

Answer 19

e results of the sedimentation
rate, c-reactive protein, heart rate, and cardiac function. The family does not need to be with the
client 24 hours a day unless carditis develops and his condition deteriorates.
CN: Basic care and comfort; CL: Synthesize
19. 1. Tinnitus is an adverse effect of prolonged aspirin therapy and the child should be examined
by a health care provider for hearing loss. Itchy skin commonly accompanies the rash associated with
rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with
food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after
ingesting aspirin can be caused by inadequate fluid intake during administration.
CN: Pharmacological and parenteral therapies; CL: Analyze

Question 20

20. Which of the following outcomes indicates that the activity restriction necessary for a 7-year-
    old child with rheumatic fever during the acute phase has been effective?
21. Joints demonstrate absence of permanent injury.
22. The resting heart rate is between 60 and 100 bpm.
23. The child exhibits a decrease in chorea movements.
24. The subcutaneous nodules over the joints are no longer palpable.

Answer 20

20. 2. During the acute phase of rheumatic fever, the heart is inflamed and every effort is made to
       reduce the work of the heart. Bed rest with limited activity is necessary to prevent heart failure.
       Therefore, the most reliable indicator that activity restriction has been effective is a resting heart rate
       between 60 and 100 bpm, normal for a 7-year-old child. No permanent damage to the joints occurs
       with rheumatic fever. The chorea movements associated with rheumatic fever are self-limited and
       usually disappear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules
       that occur over joint surfaces also resolve over time with no treatment. Therefore, they are not
       appropriate for evaluating the effectiveness of activity restrictions.
       CN: Physiological adaptation; CL: Evaluate

Question 21

21. Which of the following initial physical findings indicate the development of carditis in a
child with rheumatic fever?
1. Heart murmur.
2. Low blood pressure.
3. Irregular pulse.
4. Anterior chest wall pain.

Answer 21

21. 1. In rheumatic fever, the connective tissue of the heart becomes inflamed, leading to carditis.
       The most common signs of carditis are heart murmurs, tachycardia during rest, cardiac enlargement,
       and changes in the electrical conductivity of the heart. Heart murmurs are present in about 75% of all
       clients during the first week of carditis and in 85% of clients by the third week. Signs of carditis do
       not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not
       irregular.
       CN: Physiological adaptation; CL: Analyze

Question 22

22. The primary health care provider prescribes pulse assessments through the night for a 12-
    year-old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the
    mother that this is to evaluate if the elevated heart rate is caused by:
23. The morning digitalis.
24. Normal activity during waking hours.
25. A warmer daytime environment.
26. Normal variations in day and evening hours.

Answer 22

22. 2. An above-average pulse rate that is out of proportion to the degree of activity is an early
       sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether
       the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities.
       The environmental temperature would need to be quite warmer before it could influence the heart
       rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.
       CN: Reduction of risk potential; CL: Analyze

Question 23

23. Which of following should the nurse perform to help alleviate a child’s joint pain associated
    with rheumatic fever?
24. Maintaining the joints in an extended position.
25. Applying gentle traction to the child’s affected joints.
26. Supporting proper alignment with rolled pillows.
27. Using a bed cradle to avoid the weight of bed linens on joints

Answer 23

23. 4. For a child with arthritis associated with rheumatic fever, the joints are usually so tender
       that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help
       remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not
       positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is
       not recommended because traction is usually used to relieve muscle spasms, not typically associated
       with rheumatic fever. Supporting the body in good alignment and changing the client’s position are
       recommended, but these measures are not likely to relieve pain.
       CN: Basic care and comfort; CL: Synthesize

Question 24

The Client with Kawasaki Disease
24. When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of
Kawasaki disease (KD), which of the following should be the priority?
1. Taking vital signs every 6 hours.
2. Monitoring intake and output every hour.
3. Minimizing skin discomfort.
4. Providing passive range-of-motion exercises.

Answer 24

The Client with Kawasaki Disease
24. 2. Cardiac status must be monitored carefully in the initial phase of KD because the child is at
high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently
for signs of CHF, which would include respiratory distress and decreased urine output. Vital signs
would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing
skin discomfort would be important, it does not take priority over monitoring the child’s hourly intake
and output. Passive range-of-motion exercises would be done if the child develops arthritis.
CN: Physiological adaptation; CL: Create

Question 25

25. A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and
states that the child has been exposed to influenza. Which recommendations should the nurse make?
Select all that apply.
1. Increase fluid intake.
2. Stop the aspirin.
3. Keep the child home from school.
4. Watch for fever.
5. Weigh the child daily.

Answer 25

25. 2, 4. Aspirin needs to be stopped because of its possible link to Reye syndrome. Additionally,
    the parents need to watch for signs and symptoms of influenza. Children with influenza frequently
    present with fever, cold symptoms, and gastrointestinal symptoms. Increasing the child’s fluid intake
    and weighing the child daily are not needed at this time because the child is not ill. Keeping the child
    home from school is not necessary, because the child is not ill and has already been exposed.
    CN: Reduction of risk potential; CL: Synthesize

Question 26

26. A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat,
    and exhibits peeling skin on the hands and feet. The nurse should do which of the following first?
27. Apply lotion to the hands and feet.
28. Offer foods the toddler likes.
29. Place the toddler in a quiet environment.
30. Encourage the parents to get some rest.

Answer 26

26. 3. One of the characteristics of children with KD is irritability. They are often inconsolable.
       Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart.
       Although peeling of the skin occurs with KD, the child’s irritability takes priority over applying lotion
       to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what
       is served. There is no indication that the parents need rest. Additionally, in this situation, the child
       takes priority over the parents.
       CN: Physiological adaptation; CL: Synthesize

Question 27

27. Which of the following should the nurse include when completing discharge instructions for
    the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged
    home?
28. Offer the child extra fluids every 2 hours for 2 weeks.
29. Take the child’s temperature daily for several days.
30. Check the child’s blood pressure daily until the follow-up appointment.
31. Call the primary health care provider if the irritability lasts for 2 more weeks.

Answer 27

27. 2. The child’s temperature should be taken daily for several days after discharge, because
       recurrent fever may develop. Offering the child fluids every 2 hours is not necessary. Doing so
       increases the child’s risk for CHF. Checking the child’s blood pressure at home usually is not included
       as part of the discharge instructions because, by the time of discharge, the child is considered stable
       and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may
       last for 2 months after discharge.CN: Physiological adaptation; CL: Create

Question 28

The Client with Sickle Cell Anemia
28. A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis.
Her family is planning a ski vacation in the mountains. What should the nurse tell the parents?
1. Encourage them to go on the trip.
2. Go on the trip, but find a sitter for the 14-year-old.
3. Suggest the trip be postponed until next year.
4. Explain that the high altitude may cause a crisis.

Answer 28

The Client with Sickle Cell Anemia
28. 4. High altitude causes deoxygenation, which might precipitate a crisis. In clients with sickle
cell anemia, cells sickle when the client experiences any situation where increased demand for
oxygen is needed, such as in an infection or dehydration, or when low oxygen concentration is
experienced, such as in high altitudes or deep sea diving. Crises can commonly be prevented by
maintaining hydration. It would be unsafe to encourage the family, or to say nothing about taking the
client to high altitude areas, but giving the parents adequate information will allow them to make an
appropriate decision. Postponing the trip or leaving the child at home does not address the immediate
concern for the child’s health.
CN: Health promotion and maintenance; CL: Synthesize

Question 29

29. The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how
    to prevent sickle cell crisis, she should include which instruction?
30. Restrict the child’s fluid intake to less than 1 quart per day.
31. Drink at least 2 quarts of fluids per day.
32. Stay away from other teenagers.
33. Avoid physical activity.

Answer 29

29. 2. Increasing fluid intake and being well hydrated will help prevent cell stasis in the small
       vessels. Restricting fluids causes stasis of red blood cells and promotes obstruction and increases the
       chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell disease
       should stay away from others who have infections. When the spleen of a client who has sickle cell
       disease has become fibrotic and nonfunctional, the client is more susceptible to infections. Clients
       with sickle cell disease should not avoid physical activity as long as the client stays well hydrated.
       CN: Health promotion and maintenance; CL: Synthesize

Question 30

30. The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell
    crisis that the local tissue damage the child has on admission is caused by which of the following?
31. Autoimmune reaction complicated by hypoxia.
32. Lack of oxygen in the red blood cells.
33. Obstruction to circulation.
34. Elevated serum bilirubin concentration.

Answer 30

30. 3. Characteristic sickle cells tend to cause “log jams” in capillaries. This results in poor
       circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease
       is an abnormality in the structure of the red blood cells. The erythrocytes are sickle-shaped, rough in
       texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated
       serum bilirubin concentrations are associated with jaundice, not sickle cell disease.
       CN: Physiological adaptation; CL: Apply

Question 31

31. The mother asks the nurse why her child’s hemoglobin was normal at birth but now the child
    has S hemoglobin. Which of the following responses by the nurse is appropriate?
32. “The placenta bars passage of the hemoglobin S from the mother to the fetus.”
33. “The red bone marrow does not begin to produce hemoglobin S until several months after
    birth.”
34. “Antibodies transmitted from you to the fetus provide the newborn with temporary immunity.”
35. “The newborn has a high concentration of fetal hemoglobin in the blood for some time after
    birth.”

Answer 31

31. 4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of
       a newborn’s hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin
       S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin
       S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of
       conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term.
       The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive
       immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission
       of antibodies is important to protect the infant from various infections during early infancy.
       CN: Physiological adaptation; CL: Apply

Question 32

The Client with Iron Deficiency Anemia
32. Which of the following actions indicates that the parents of a 12-month-old with iron
deficiency anemia understand how to administer iron supplements? Select all that apply.
1. They administer iron supplements in combination with fruit juice.
2. They administer iron supplements with meals.
3. They report dark stools.
4. They brush the child’s teeth after administering the iron supplements.
5. They decrease dietary intake of foods fortified with iron.

Answer 32

The Client with Iron Deficiency Anemia
32. 1, 4. Parent teaching concerning a child with iron deficiency anemia should include directions
about giving iron combined with fruit juice, in divided doses, between meals, and with a dropper for
a 12-month-old or through a straw for older toddlers. Iron stains teeth; so brushing the teeth and
administering liquid iron through a dropper or straw are necessary to prevent staining the teeth. Iron
should not be given with milk, antacids, or tea and should be administered on an empty stomach. Iron
will cause the stool to become black or green, which is normal and does not need to be reported.However, light-colored stools indicate the iron is not being absorbed and should be reported.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 33

33. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent
    infections. The nurse responds based on the understanding of which of the following?
34. Little is known about iron deficiency anemia and its relationship to infection in children.
35. Children with iron deficiency anemia are more susceptible to infection than are other children.
36. Children with iron deficiency anemia are less susceptible to infection than are other children.
37. Children with iron deficiency anemia are equally as susceptible to infection as are other
    children.

Answer 33

33. 2. Children with iron deficiency anemia are more susceptible to infection because of marked
       decreases in bone marrow functioning with microcytosis.
       CN: Physiological adaptation; CL: Apply

Question 34

34. Which statements by the mother of a toddler should lead the nurse to suspect that the child is
    at risk for iron deficiency anemia? Select all that apply.
35. “He drinks over three cups of milk per day.”
36. “I can’t keep enough apple juice in the house; he must drink over 10 oz per day.”
37. “He refuses to eat more than two different kinds of vegetables.”
38. “He doesn’t like meat, but he will eat small amounts of it.”
39. “He sleeps 12 hours every night and takes a 2-hour nap.”

Answer 34

34. 1, 2. Toddlers should have between two and three cups of milk per day and 8 oz of juice per
    day. If they have more than that, then they are probably not eating enough other foods, including iron-
    rich foods that have the needed nutrients. Food preferences vary among children. It is acceptable for
    the child to refuse foods as long as the diet is balanced and contains adequate calories. The child is
    obtaining a normal amount of sleep.
    CN: Basic care and comfort; CL: Evaluate

Question 35

35. Which of the following foods should the nurse encourage the mother to offer to her child with
    iron deficiency anemia?
36. Rice cereal, whole milk, and yellow vegetables.
37. Potato, peas, and chicken.
38. Macaroni, cheese, and ham.
39. Pudding, green vegetables, and rice.

Answer 35

35. 2. Potatoes, peas, chicken, green vegetables, and rice cereal contain significant amounts of
       iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources.
       Rice by itself also is not a good source of iron. Macaroni, cheese, and ham are not high in iron. While
       pudding (made with fortified milk) and green vegetables contain some iron, the better diet has protein
       and iron from the chicken and potato.
       CN: Basic care and comfort; CL: Apply

Question 36

The Client with Hemophilia
36. What is the most appropriate method to use when drawing blood from a child with
hemophilia?
1. Use finger punctures for lab draws.
2. Prepare to administer platelets.
3. Apply heat to the extremity before venipunctures.
4. Schedule all labs to be drawn at one time.

Answer 36

The Client with Hemophilia
36. 4. Coordinating labs to minimize sticks reduces trauma and the risk of bleeding. Finger sticks
in general are more painful and associated with more bleeding than venipunctures. In hemophilia,
platelets are typically normal. Heat would increase vasodilatation and increase bleeding.
CN: Reduction of risk potential; CL: Apply

Question 37

37. A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions
    should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
38. Administer one-half of a children’s aspirin for a temperature higher than 101°F (38.3°C).
39. Sew thick padding into the elbows and knees of the child’s clothing.
40. Check the color of the child’s urine every day.
41. Expect the eruption of the primary teeth to produce moderate to severe bleeding.

Answer 37

37. 2. As the hemophilic infant begins to acquire motor skills, the risk of bleeding increases
       because of falls and bumps. Such injuries can be minimized by padding vulnerable joints. Aspirin is
       contraindicated because of its antiplatelet properties, which increase the infant’s risk for bleeding.
       Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is
       not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause
       moderate to severe bleeding episodes in children with hemophilia.
       CN: Safety and infection control; CL: Synthesize

Question 38

38. A child with hemophilia presents with a burning sensation in the knee and reluctance to move
    the body part. The nurse collaborates with the care team to provide factor replacement and:
39. Administer an aspirin-containing compound.
40. Institute rest, ice, compression, and elevation (RICE).
41. Begin physical therapy with active range of motion.
42. Initiate skin traction.

Answer 38

38. 2. The child is displaying symptoms of bleeding in the joint and factor replacement is
       indicated. The RICE method is used additionally as a supportive measure to help control the
       bleeding. Aspirin containing compounds contribute to bleeding and should never be used to control
       pain. Physical therapy is instituted after the acute bleeding to prevent further damage. Orthopedic
       traction is considered in some rare cases during the rehabilitation phase, but not the acute phase.
       CN: Physiological adaptation; CL: Synthesize

Question 39

39. Because of the risks associated with administration of factor VIII concentrate, the nurse
    should teach the child’s family to recognize and report which of the following?
40. Yellowing of the skin.
41. Constipation.
42. Abdominal distention.
43. Puffiness around the eyes.

Answer 39

39. 1. Because factor VIII concentrate is derived from large pools of human plasma, the risk of
       hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous
       membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal
       distention, or puffiness around the eyes.CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 40

40. The mother tells the nurse she will be afraid to allow her child with hemophilia to participate
    in sports because of the danger of injury and bleeding. After explaining that physical fitness is
    important for children with hemophilia, which of the following activities should the nurse suggest as
    ideal?
41. Snow skiing.
42. Swimming.
43. Basketball.
44. Gymnastics.

Answer 40

40. 2. Swimming is an ideal activity for a child with hemophilia because it is a noncontact sport.
       Many noncontact sports and physical activities that do not place excessive strain on joints are also
       appropriate. Such activities strengthen the muscles surrounding joints and help control bleeding in
       these areas. Noncontact sports also enhance general mental and physical well-being. Falls and
       subsequent injury to the child may occur with snow skiing. Basketball is a contact sport and therefore
       increases the child’s risk for injury. Gymnastics is a very strenuous sport. Gymnasts frequently have
       muscle and joint injuries that result in bleeding episodes.
       CN: Health promotion and maintenance; CL: Apply

Question 41

The Client with Leukemia
41. A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic
leukemia. Which of the following signs and symptoms require the most immediate nursing
intervention?
1. Fatigue and anorexia.
2. Fever and petechiae.
3. Swollen neck lymph glands and lethargy.
4. Enlarged liver and spleen.

Answer 41

The Client with Leukemia
41. 2. Fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of
normal white blood cells and thrombocytes by the bone marrow and put the client at risk for other
infections and bleeding. The nurse should initiate infection control and safety precautions to reduce
these risks. Fatigue is a common symptom of leukemia due to red blood cell suppression. Although
the client should be told about the need for rest and meal planning, such teaching is not the priority
intervention. Swollen glands and lethargy may be uncomfortable but they do not require immediate
intervention. An enlarged liver and spleen do require safety precautions that prevent injury to the
abdomen; however, these precautions are not the priority.
CN: Reduction of risk potential; CL: Analyze

Question 42

42. A 12-year-old with leukemia is receiving cyclophosphamide. The nurse should assess for the
adverse effect of:
1. Photosensitivity.
2. Ataxia.
3. Cystitis.
4. Cardiac arrhythmias.

Answer 42

42. 3. Cystitis is a potential adverse effect of cyclophosphamide. The client should be monitored
       for pain on urination. Photosensitivity, ataxia, and cardiac arrhythmias are not adverse effects
       associated with cyclophosphamide.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 43

43. After teaching the parents of a child newly diagnosed with leukemia about the disease, which
    of the following descriptions given by the mother best indicates that she understands the nature of
    leukemia?
44. “The disease is an infection resulting in increased white blood cell production.”
45. “The disease is a type of cancer characterized by an increase in immature white blood cells.”
46. “The disease is an inflammation associated with enlargement of the lymph nodes.”
47. “The disease is an allergic disorder involving increased circulating antibodies in the blood.”

Answer 43

43. 2. Leukemia is a neoplastic, or cancerous, disorder of blood-forming tissues that is
       characterized by a proliferation of immature white blood cells. Leukemia is not an infection,
       inflammation, or allergic disorder.
       CN: Physiological adaptation; CL: Evaluate

Question 44

44. Which of the following is the highest risk for a child with Leukemia whose lab values are as
    follows: WBC 6,500 mm 3 (6.5 × 10 9 /L), platelet count 40,000 μL (40 × 10 9 /L), and HCT 41.2%
    (0. 412)?
45. Activity intolerance.
46. Bleeding.
47. Impaired tissue perfusion.
48. Infection.

Answer 44

44. 2. A normal platelet count is 150,000 μL to 400,000 μL (150 to 400 × 10 9 /L). A platelet count
       of 40,000 μL (40 × 10 9 /L) is low and puts the child at risk for injury, bruising, and bleeding.
       Hematocrit of 41.2% (0.412) is normal; therefore, the child will have adequate oxygenation and
       tissue perfusion. 6,500 mm 3 (6.5 × 10 9 /L) is a normal white count, therefore, the child has no increase
       in risk for infection.
       CN: Reduction of risk potential; CL: Analyze

Question 45

45. Which of the following statements should the nurse use to describe to the parents why their
    child with leukemia is at risk for infections?
46. “Play activities are too strenuous.”
47. “Vitamin C intake is reduced over a period of time.”
48. “The number of red blood cells is inadequate for carrying oxygen.”
49. “Immature white blood cells are incapable of handling an infectious process.”

Answer 45

45. 4. In leukemia, the number of normal white blood cells that are capable of fighting an infection
       is decreased. Although there is an increased number of immature white blood cells, they are unable to
       combat infection. Therefore, a child with leukemia is subject to infection. The major morbidity and
       mortality factor associated with leukemia is infection resulting from the presence of granulocytopenia.
       While increased activity may cause fatigue, it does not put the child at risk for infection. Vitamin C
       intake should not decrease if the child has adequate dietary intake. Decreased red blood cells are not
       directly caused by infection.CN: Reduction of risk potential; CL: Apply

Question 46

46. Which of the following beverages should the nurse plan to give a child with leukemia to
relieve nausea?
1. Orange juice.
2. Weak tea.
3. Plain water.
4. A carbonated beverage.

Answer 46

46. 4. Carbonated beverages ordinarily are the best tolerated when a child feels nauseated. Many
       children find cola drinks especially easy to tolerate, but noncola beverages are also recommended.
       Orange juice usually is not tolerated well because of its high acid content. Tea may also be too acidic
       and many children do not like tea. Water does not relieve nausea.
       CN: Basic care and comfort; CL: Apply

Question 47

47. Which of the following medication prescriptions to help relieve discomfort in a child with
leukemia should the nurse question?
1. Hydromorphone.
2. Acetaminophen with codeine.
3. Ibuprofen.
4. Acetaminophen with hydrocodone

Answer 47

47. 3. Ibuprofen prolongs bleeding time and is contraindicated in clients with leukemia.
       Nonnarcotic drugs other than ibuprofen or aspirin, such as acetaminophen, may be prescribed to
       control pain and may be used in combination with codeine or hydrocodone if pain is more severe.
       Hydromorphone may also be used for severe pain.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 48

48. After teaching a child with leukemia scheduled for a bone marrow aspiration about the
    procedure, the nurse determines that the teaching has been successful when the child identifies which
    of the following as the site for the aspiration?
49. Right lateral side of the right wrist.
50. Middle of the chest.
51. Distal end of the thigh.
52. Back of the hipbone.

Answer 48

48. 4. Although bone marrow specimens may be obtained from various sites, the most commonly
       used site in children is the posterior iliac crest, the back of the hipbone. This area is close to the
       body’s surface but removed from vital organs. The area is large, so specimens can easily be obtained.
       For infants, the proximal tibia and the posterior iliac crest are used. The middle of the chest or
       sternum is the usual site for bone marrow aspiration in an adult. The wrist, chest, and thigh are not
       sites from which to obtain bone marrow specimens.
       CN: Reduction of risk potential; CL: Evaluate

Question 49

49. The nurse and parents are planning for the discharge of a child with leukemia who is
    receiving dactinomycin and vincristine. The nurse should teach the parents to:
50. Encourage increased fluid intake.
51. Keep the child out of the sun.
52. Monitor the child’s heart rate.
53. Observe the child for drowsiness.

Answer 49

49. 1. Dactinomycin and vincristine both cause nausea and vomiting. Oral fluids are encouraged,
       and antiemetics are given to prevent dehydration. Avoiding sun exposure is not necessary because
       photosensitivity is not associated with these drugs. Heart rate changes and drowsiness also are not
       associated with either of these two drugs.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 50

50. After doing well for a period of time, a child with leukemia develops an overwhelming
    infection. The child’s death is imminent. Which of the following statements offers the nurse the best
    guide in making plans to assist the parents in dealing with their child’s imminent death?
51. Knowing that the prognosis is poor helps prepare relatives for the death of children.
52. Relatives are especially grieved when a child does well at first but then declines rapidly.
53. Trust in health care personnel is most often destroyed by a death that is considered untimely.
54. It is more difficult for relatives to accept the death of an older child than that of a toddler.

Answer 50

50. 2. It has been found that parents are more grieved when optimism is followed by defeat. The
       nurse should recognize this when planning various ways to help the parents of a dying child. It is not
       necessarily true that knowing about a poor prognosis for years helps prepare parents for a child’s
       death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily
       destroyed when a death is untimely if the family views the personnel as having done all that was
       possible. It is not more difficult for parents to accept the death of an older child than that of a younger
       child.
       CN: Psychosocial integrity; CL: Synthesize

Question 51

51. A 12-year-old with leukemia will be taking vincristine. The nurse should encourage the child
to eat what kind of diet?
1. High-residue.
2. Low-residue.
3. Low-fat.
4. High-calorie.

Answer 51

51. 1. Vincristine may cause constipation, so the client should be encouraged to eat a high-residue
       (fiber) diet. The other diets do not help with constipation that can occur while receiving vincristine.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 52

52. A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse
    should instruct the child and parents to:
53. Continue with immunizations.
54. Not receive any live attenuated vaccines.
55. Receive vitamin and mineral supplements.
56. Stay away from peers.

Answer 52

52. 2. Children who are immunosuppressed should not receive any live attenuated vaccines.
       Clients who are immunosuppressed and are given live attenuated vaccines such as measles, mumps,
       rubella and oral polio vaccine can develop severe forms of the diseases for which they are being
       immunized, which can result in death. Inactivated vaccines may be given if necessary, but the client is
       not able to adequately produce needed antibodies and it is recommended that immunizations be
       delayed for 3 months after the immunosuppressive drugs have been discontinued. Vitamin and mineralsupplements are not normally given in conjunction with immunosuppressive drugs. When the client is
       immunosuppressed, the client should avoid only persons who have an infection.
       CN: Health promotion and maintenance; CL: Synthesize

Question 53

53. A nurse is teaching the family of an 8-year-old boy with acute lymphocytic leukemia about
    appropriate activities. Which of the following activities should the nurse recommend?
54. Home schooling.
55. Restriction from participating in athletic activities.3. Avoiding trips to the shopping mall.
56. Being treated as “normal” as much as possible.

Answer 53

53. 4. Any child with a chronic illness should be treated as normally as possible. Unless the child
       has severe bone marrow depression, he should be allowed to go to school with others and can go to
       the mall. If the child is in remission, athletic activities are allowed.
       CN: Health promotion and maintenance; CL: Synthesize

Question 54

Managing Care Quality and Safety
54. A transfusion of packed red blood cells has been prescribed for a 1-year-old with a sickle
cell anemia. The infant has a 25-gauge IV infusing dextrose with sodium and potassium. Using the
situation, background, assessment, recommendation (SBAR) method of communication, the nurse
contacts the primary health care provider and recommends:
1. Starting a second IV with a 22-gauge catheter to infuse normal saline with the blood.
2. Using the existing IV, but changing the fluids to normal saline for the transfusion.
3. Replacing the IV with a 22-gauge catheter to infuse the prescribed fluids.
4. Starting a second IV with a 25-gauge catheter to infuse normal saline with the transfusion.

Answer 54

Managing Care Quality and Safety
54. 2. The best evidence indicates that a catheter as small as 27-gauge may safely be used for
transfusion in children, but blood must be infused with normal saline, not dextrose. A 1-year-old
should be able to maintain their blood glucose for the 2-hour duration of the infusion without the need
for a second IV.
CN: Management of care; CL: Synthesize

Question 55

55. An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to
correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
Select all that apply.
1. Administering oral medications.
2. Administering IV morphine.
3. Obtaining vital signs.
4. Morning hygiene.
5. Circulation checks.
6. Discharge teaching.

Answer 55

55. 1, 3, 4. The RN’s scope of practice includes assessment, planning, implementing, and
    evaluation. Only aspects of care implementation may be delegated to the LPN and the exact skills that
    may be delegated vary by state and institution. In general, LPNs have been trained to perform the
    tasks of administering oral medications, performing hygiene, and recording the intake and output.
    LPNs may also take vital signs to gather data, but the nurse must interpret the data. Administering IV
    morphine requires assessment of the client’s respiratory status before, during, and after the procedure.
    Circulation checks are assessments the nurses should complete.
    CN: Management of care; CL: Synthesize

Question 56

56. The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow
    biopsy. The nurse’s most important responsibility during the procedure is to:
57. Administer the topical anesthetic.
58. Keep the parents informed.
59. Monitor the client.
60. Record the procedure.

Answer 56

56. 3. During conscious sedation the client may lose protective reflexes and adequate respiratory
       and cardiac function may be impaired. At every procedure there must be one health care professional
       whose sole responsibility is to monitor the client. Topical agents must be given in advance of the
       procedure to be effective. During the procedure, the nurse would not leave the child to speak with
       parents. While the procedure would be documented according to the facility’s protocols, proper
       monitoring of the client is the intervention most associated with reducing risks.
       CN: Reduction of risk potential; CL: Apply

Question 57

57. The nurse is transferring a child who has had open heart surgery from the intensive care unit
    to the pediatric unit. The child’s blood pressure has been fluctuating but has been stable during the last
    2 hours. The nurse from the pediatric intensive care unit should include which of the following
    information in the report to the nurse on the pediatric unit? Select all that apply.
58. Medications being used.
59. Current vital signs.
60. Potential for blood pressure to drop.
61. Drip rate for the intravenous infusion.
62. Time of the most recent dose of pain medication.
63. Medications given during surgery.

Answer 57

57. 1, 2, 3, 4, 5. The report made when nurses are “handing off” a client from one nursing unit to
    another must include information about the condition of the client, potential for changes in the client’s
    condition, current medications, and care and services received. It is not necessary to know what
    medications were given in surgery to provide safe care at this point.
    CN: Safety and infection control; CL: Synthesize

Question 58

58. The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect.
    The nurse verifies the child’s identity by checking the arm band and:
59. Asking the child to state her name.
60. Checking the room number.
61. Asking the child to tell her birth date.
62. Asking the parent the child’s name.

Answer 58

58. 4. Safety standards require the use of two identifiers prior to medication administration. A
       parent can be used as the second identifier. Many young children will only answer to a nickname that
       does not coincide with the medical identification band or may answer to any name. It is common for
       children on a pediatric floor to go into each other’s rooms. A small child may not know their birth
       date.
       CN: Safety and infection control; CL: Synthesize