1 Instructor s Manual Chapter 4 Community and Home Health Nursing Answers to Study Questions 1. The community health nurse is contracted to do a follow-up assessment on a 5-yearold child diagnosed with a ventricular septal defect (VSD). A postcardiac catheterization has been recommended this morning. The mother asks the nurse why her child requires further testing. The best response by the nurse is: a. This test determines the exact location of the problem in the heart. b. It is important to evaluate the strength of the heart muscle. c. We need to assess the electrical function of the heart. d. The presence of a murmur will be documented. Answer: a. A cardiac catheterization identifies the site of the defect and allows the physicians to measure various pressures in the heart. Muscle strength can be evaluated with an echocardiogram. An electrocardiogram measures electrical activity. Murmurs are identified with a stethoscope. 2. An 8-year-old boy bedridden at home needs a PPD test. The child refuses to allow the test. The community health nurse s most appropriate response is: a. Your parents want you to have this test. b. You are old enough to know that shots help you. c. Your parents have consented to this so I must give it to you. d. You seem to be really afraid of this injection so let s talk about it.
2 Answer: d. The nurse is responding to the fears the child has verbalized in a therapeutic manner. In option a the focus is on the parent and not the child. Option b does not address the fears of the child and is not appropriate. Parental consent and the child s fear are different issues. 3. The community health nurse is teaching a class for mothers of toddlers at a local church. The nurse explains that household cleaning items, medications, and jewelry are kept out of reach because: a. toddlers have an increased appetite. b. toddlers have a heightened level of oral activity. c. toddlers will become rebellious teenagers if disciplined. d. toddlers consume many items that are not nutritious. Answer: b. Toddlers explore their environments by putting objects in the mouth. They are generally picky eaters and do not have an increased appetite. They typically follow direction from caregivers. They usually do not consume nonfood items. 4. A child diagnosed with leukemia on chemotherapy is discharged home. The community health nurse assesses the parents accurate knowledge of discharge instructions when the parents say: a. I will allow my child to eat whatever and whenever she wants to eat. b. My child cannot be around other children. c. Every two hours I have a game for her to play. d. We will go to the park daily.
3 Answer: a. Nutrition is vital for overall health while on chemotherapy and the child should eat as desired. It is impossible to isolate a child at home, but anyone with infectious disease should limit contact. Play should be structured as well as spontaneous. The child may be too weak for daily physical activity. 5. The community health nurse is assessing a 3-year-old girl from a preschool with teacher concerns about development. The nurse refers the child to early intervention services based on which data? a. A ball is kicked twenty feet. b. Potty training is problematic. c. Stringing beads in art class is difficult. d. A twenty-word vocabulary. Answer: d. A 3-year-old child typically has a vocabulary of at least two hundred words. Children at this age can kick balls. Potty training is sporadic until age 3. Children may have difficulty mastering fine motor movements at this age. 6. A child on a ventilator with a tracheostomy is cared for at home by the parents with the assistance of a licensed practical nurse. The child has a pulse oximeter for daily oxygen saturation measurements. The community health nurse teaches the family to call 911 if: a. the pulse is above 100. b. the oxygen saturation is below 95%. c. the child has pink lips and nail beds.
4 d. the child has a temperature of 99.4 degrees F. Answer: b. Oxygen saturation above 95% is necessary to oxygenate the vital organs. The child needs an immediate medical intervention (i.e., call 911) if the oxygen saturation level falls below 95%. A pulse could be elevated for many reasons such as anxiety or pain. Pink lips, ear lobes, and nail beds are a sign of adequate oxygenation. A slightly elevated temperature could mean dehydration but an infection needs to be ruled out. The physician should be called, and the registered nurse can assess for signs and symptoms of infection. 7. A 12-year-old boy diagnosed with type 1 diabetes is referred to the community health nurse because of erratic blood glucose levels. The nurse suspects the child is not following the diet, based on behavioral cues during the visit. The child tells the nurse he is experiencing headaches. The most appropriate nursing action is to: a. test the urine for ketones. b. give the child a cup of milk. c. ask the child what and when was the last meal. d. obtain a blood glucose level via the accucheck. Answer: d. Glucose reading will confirm hypoglycemia. Ketones will not tell you the glucose level, but may be important. Milk will increase the glucose level and skew the test results. Food recall is important but will not assist in knowing the glucose level at the visit. 8. An infant on home care services has a diagnosis of gastroesophageal reflux (GERD). The nurse teaches the caregivers the best practice when feeding the child by stating:
5 a. Discontinue breastfeeding. b. Keep the child in a prone position. c. Thicken formula with rice cereal. d. Obtain weights on a daily basis. Answer: c. Thickened formula can reduce vomiting episodes. Breast milk is recommended for infants and can be given in a bottle; however, discontinuation of breastfeeding does not address GERD. Infants with GERD need to be in a semi- Fowlers position, not prone. Weights do not address intake but rather output in relation to fluid status. 9. A mother of a 2-year-old girl with a seizure disorder is visited by the community health nurse. Seizure precautions are reviewed and the nurse prioritizes which action for the mother to follow during a seizure? a. Call 911. b. Hold the child during the seizure. c. Place the child on his or her side. d. Loosen the child s clothing. Answer: c. Placing the child on the side will decrease the risk of aspiration. Children with seizure disorders are managed at home with drugs like Diastat per rectum for rescue. Holding a child during a seizure may cause injury. Loosening tight clothing is a comfort measure.
6 10. Disaster preparedness is essential when chronically ill children are cared for in their home. The community health nurse is responsible to assist families in disaster preparation by identifying essential elements in a plan. Which of the following items are essential? Select all that apply. a. detailed list of medications b. flashlights and batteries c. canned foods and drinks d. equipment for blood pressure e. corded and cell phone f. emergency phone numbers Answers: a, b, c, e, and f. All these items and more are needed in case of a disaster except d. Blood pressure monitoring is not essential without the means to treat in a disaster.