Answers to Clinical Reasoning in Action Scenarios and Questions, in 1
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
Answers to Clinical Reasoning in Action Scenarios and Questions in
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
Chapter 1: Nurse's Role in Care of the Child: Hospital, Community, and Home
Recall 3-year-old Manny, at the beginning of the chapter, who has a seizure disorder. He receives
his care in a mobile van sent to his community by the local children’s hospital. Manny has a
regular source of care because his family income qualifies him for the state’s Child Health
Insurance Program (CHIP).
1. Explain the standards of pediatric nursing care as they relate to caring for Manny and
his family.
Answer: The nurse is responsible for collecting patient health data, analyzing assessment data to
develop nursing diagnoses, identifying expected outcome for Manny and his family, developing
a plan of care that will help the Manny and his family achieve the expected outcomes, and
implementing the nursing interventions listed in the care plan in a safe maner in collaboration
with the family. The nurse should also maintain current knowledge in the care of children with
seizures, and to evaluate the quality and effectiveness of care provided.
2. Identify at least four different settings in which a child with a seizure disorder could
receive health care.
Answer: The child may receive care in a physician’s office, community health center, a hospital
pediatric outpatient clinic, or school health center. The child may also receive care in the hospital,
usually when being treated for a different condition other than seizures.
3. List three specific injury prevention messages for a child of Manny’s age that should be
provided to Manny’s parents to reduce his risk for morbidity and mortality.
Answer: Manny is a 3 year-old boy. The education to the parents to decrease the risk for
morbidity and mortality should include, but may not be limited to the following: Morbidity:
unintentional injury and disease prevention, specifically injuries related to children with a seizure
disorder. The child with a seizure disorder is at increased risk for drowning. The child should not
be left unattended in a bathtub, wading pool or while swimming. The caregivers need education
to know how to protect the child during the seizure event. The care givers should be aware of the
need to ease the child to the floor, move away hard objects that the child could strike during the
tonic and clonic movements of seizure, and provide a general safe environment during the
seizure activity. Other considerations for children of all ages should include information on
wearing helmet with tricycle, bicycle, or skating; car seat safety, general safety concerns in the
home such as baby locks for cabinets, drawers; safety equipment such as gates to prevent falls
down stairs; and other home safety tools such as smoke detectors and family plans for evacuation
in the event of a fire.
4. List specific steps that should be used in the healthcare setting to ensure that an error is
avoided when prescribing Manny's seizure medication.
Answer: The healthcare setting should have specific guidelines for administration of pediatric

Answers to Clinical Reasoning in Action Scenarios and Questions, in 2
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
medications because of the complexity in calculating dosages and the different formulations of
medications (e.g., tablets, liquids, drops). The nurse must take steps to ensure that the child
receives the correct medication in the right dosage at the right time, and by the right route of
administration. Do not rely on memory; verify medication dosages and medication dosage
calculations. Every prescription should include the child's weight and age, as well as the
calculated dose and mg/kg dose. A zero should not be used after a decimal. The administration rate
for all IV medication should be specified. Drug interactions and patient allergies cause adverse
reactions and should be checked prior to administration of medications.

Answers to Clinical Reasoning in Action Scenarios and Questions, in 3
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
Chapter 2: Family-Centered Care and Cultural Considerations
Casey, a 16-year-old, is recuperating from injuries sustained in a motor vehicle crash in which he
was the passenger. He was not wearing a seat belt and experienced a brain injury after striking the
windshield. His cognitive and motor functions are impaired. Following a 7-day acute care hospital
stay, he was moved to an inpatient rehabilitation hospital where he has been for the past 5 days.
He is much more responsive to stimuli and to family members 12 days after his injury. Physical
therapy is provided twice a day to promote range of motion and muscle tone and to prevent
contractures. Plans are being made to discharge him home with outpatient rehabilitation care
within the next 5 days. A case manager will be assigned to coordinate his healthcare services.
Casey lives with his mother, two half-brothers (10 and 6 years old), and stepfather. Both his
mother and stepfather are employed full time and are trying to determine how to manage care for
Casey once he returns home. Casey’s grandparents live nearby and may provide some support to
the family. Because Spanish is the language spoken primarily by the family, teaching materials
are provided in both Spanish and English. Casey is totally dependent for care including bathing,
toileting, feeding, and mobilizing. Although he is expected to regain self-care abilities, the impact
of the injury on his cognitive ability and future functioning is unknown.
Casey’s extended family has provided support to the family during the past 12 days, but the level
of support in the future weeks will decrease because of other family obligations. Casey’s mother
has already initiated a leave of absence from work so she can care for him when he returns home;
however, this will mean the family has reduced income during that time period. Casey’s younger
brothers have been able to visit him, and they are very anxious because Casey cannot talk with
them. They have been trying to avoid bothering their mother and father during this time, but they
are wondering when life will be more normal and they can again participate in their usual after-
school activities.
1. What information about the family strengths, needs, and resilience can be identified
from the information above?
Answer: Family strengths include the extended family, the mom's ability to take leave of absence
from work, and two adults in the blended family. The needs start with monetary issues from one
adult being out of work, decreasing family support as time passes, and assistance for the care of
other children. The siblings in the family need consideration and support along with the parents.
Other issues to take into consideration are the 'blended-family' and the stress that may occur
because the child is biological to one parent and adopted by the other.
2. What additional information would be helpful to know about family strengths and needs
prior to developing a nursing care plan?
Answer: Additional information that would be of assistance is the family's insurance and
supplemental insurance benefits. Other financial information to assist in providing care,
especially long-term care and rehabilitation, is necessary for planning. Information about the
community support system, for the parents and the children, as well as connection with other
parts the community, would also be helpful. The family's problem-solving ability and coping
skills should also be taken into consideration. The family's cultural background and wishes
should be integrated into planning.
3. Based on your assessment of the family and challenges facing them, list at least one
nursing diagnosis (additional to those listed on page 46) that addresses issues important for
planning nursing care for Casey and his family.

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Answers to Clinical Reasoning in Action Scenarios and Questions, in 4
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
Answer: Spiritual Distress (parents) related to the child's acquired disability. Risk for Impaired
Parenting related to role strain.
4. Describe the use of family-centered care principles in planning Casey’s nursing care in
collaboration with the family.
Answer: Family-centered care is based on the idea that the family is the constant in the child's
life. Based on this, the family should be fully informed and actively participate in all treatment
decisions, and the nursing care and management for Casey.
Chapter 3: Genetic and Genomic Influences
Recall 16-year-old Sarah from the chapter-opening scenario. While at the sports clinic for a
routine physical, she questions the nurse about being tested for Huntington disease. Huntington
disease (HD) is a progressive disorder of motor, cognitive, and psychiatric disturbances.
Symptoms typically present between age 35 and 44 years, with a median survival time of 15 to 18
years after onset. HD is inherited in an autosomal dominant pattern. Sarah’s maternal grandfather
died from HD. Sarah has been reading about HD and is interested in being tested. Her mother
strongly objects; she does not want to know her own Huntington status.
Sarah’s mother, Diane, is of western European Caucasian descent. Sarah’s knowledge
about her father is limited. She knows that he is a third-generation Filipino American but has no
medical information on him or his extended family.
Sarah’s grandmother on her mother’s side has three sisters and two brothers. The two
brothers died of myocardial infarctions at the ages of 37 and 55 years, respectively. Sarah’s
maternal grandfather had no brothers but had two sisters. Her maternal grandfather died at age 62
years of Huntington disease. The sisters are alive and well and have no medical problems.
Diane has two brothers and two sisters. She is the youngest of the siblings. Her oldest
brother, Ken, was diagnosed 10 years ago with Huntington disease at age 41 years. Ken has two
daughters ages 21 and 25 years. Sarah is very close to these cousins, and she knows that they have
no medical problems beyond seasonal allergies and migraine headaches. Diane’s other brother,
Brian (age 38 years), has recently had bouts of depression and has noticed slight difficulties in
coordination and involuntary movements. Brian and his wife Sally adopted a son, Dave, with
Down syndrome, and he is 19 years old. Sarah’s brother is age 12 years and does not have any
medical problems.
1. What further data would you gather from Sarah before referring her to a genetic
specialist?
Answer: The nurse should collect a three-generation family history of Sarah’s family, including
personal, health, and developmental information, and construct a pedigree using standard symbols
and terminology. The nurse should examine the information to identify genetic risk factors, and
assess Sarah’s knowledge and perceptions about Huntington disease.
2. What are the signs and symptoms of Huntington disease? The prognosis? Is it linked to
any ethnic group?
Answer: The earliest symptoms are a general lack of coordination, minor involuntary movements,
subtle changes in eye movements, and often a depressed or irritable mood. As the disease
advances, uncoordinated, jerky body movements become more apparent, along with speech and
swallowing difficulties, a decline in mental abilities, and behavioral and psychiatric problems.
Symptoms worsen gradually, and in the late stages, involuntary movements (chorea) become
prominent, voluntary activity becomes more difficult, and speech and swallowing deteriorate.

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Answers to Clinical Reasoning in Action Scenarios and Questions, in 5
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
Mental abilities generally decline into dementia. Although the disorder itself is not fatal,
complications such as pneumonia and heart disease, and physical injury from falls reduce life
expectancy to around twenty years after symptoms begin. There is no cure for HD, and full-time
care is often required in the later stages of the disease, but there are emerging treatments to relieve
some of its symptoms. It is much more common in people of Western Europe descent than in
those from Asia or Africa.
3. Create a family pedigree for Sarah based on the family information she has provided.
What does the pedigree reveal, and what nursing actions would you plan for Sarah?
Answer: See sample pedigree for Sarah on next page. The pedigree reveals relatives with
Huntington disease (HD) on the maternal side of her family, including an uncle and a grandfather
who were diagnosed with HD and a second uncle who may be having early symptoms. Based on
that information, Sarah is at risk of inheriting HD herself through her mother, if her mother has
the Huntington mutation. An appropriate nursing action would be to assess Sarah’s interest in
seeking a genetic referral and to discuss with her the process and potential implications. Should
Sarah’s test be positive, that discussion should address the potential for inadvertently revealing
Diane’s genotype for Huntington disease. Based on Sarah’s interest, the nurse might facilitate or
advocate for a referral to a genetic specialist. The nurse should also recognize genetic red flags
for heart disease, based on two relatives with myocardial infarction at young ages.
4. What are the implications for Sarah’s family if her test is positive for HD? What if her
result is negative?
Answer: If Sarah is tested and found to be positive for the Huntington mutation (i.e, if she has 40
or more CAG repeats), she will almost certainly develop Huntington disease at some time during
middle age. Furthermore, a positive test for Sarah would reveal that her mother, Diane, also carries
the mutation. Because Diane does not wish to know her Huntington status, such an outcome would
create a difficult ethical and social situation. If Sarah’s test is negative for the mutation (i.e, reveals
less than 27 CAG repeats), then Sarah can be reassured about her own health. Her mother’s status
would remain unknown: Recall that the inheritance risk for autosomal dominant conditions is 50%,
so if Diane does have the mutation, there is a 50% chance that she would pass it to Sarah. Finally,
Sarah’s result could be indeterminate. A small proportion of individuals have an HTT allele with
reduced penetrance (36-39 CAG repeats) or an intermediate allele (27-35 CAG repeats). These
genotypes are associated with reduced penetrance of Huntington disease, or disease with later age
of onset of disease and slower progression. Some individuals in the intermediate range will never
develop symptoms. They do, however, have a small risk of having a child with a CAG expansion
(i.e., additional repeats that put the child at risk of developing Huntington disease).
5. Should Sarah be tested at this time? Give a rationale for your answer.
Answer: In general, professional guidelines recommend withholding predictive genetic testing for
adult-onset disorders until children and adolescents reach the age of majority, which is usually age
18. This guideline has received particularly broad support for conditions like Huntington disease,
for which there is no preventive treatment or means to delay disease onset or severity. Some
professionals, however, find this approach to be paternalistic and support a more open policy that
values client autonomy and voluntary decision-making. The nurse should apply anticipatory
guidance in helping Sarah decide if she would like to be referred to a genetics professional. In any
event, predictive testing requires informed consent, and genetics professionals have specific
training in supporting informed decision making in a context of open communication.

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Answers to Clinical Reasoning in Action Scenarios and Questions, in
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
Chapter 4: Growth and Development
You encounter a 12-month-old child, Julia, while working in the developmental clinic. Her
mother tells you that their family practice physician had concerns that Julia might have a
developmental delay. She was a full-term baby, and there were no complications throughout her
mother’s pregnancy or delivery. Julia’s mother tells you that she has a generally shy and slowto-
warm-up temperament. She makes little eye contact with you and prefers to sit on her mother’s
lap and cling to her arms if a stranger gets close. She is able to pick up small objects, babble,
crawl, and use her pincer grasp. She is not able to walk, hold a crayon, or speak any words. Julia
clearly has a developmental delay.
1. What are some examples of toys you can suggest to Julia’s parents based on her
developmental level (not based on her age)?
Answer: Large blocks, jack-in-the-box, push and pull toys, and toys that pop apart and back
together.
2. What are some examples of hazards you can advise Julia’s parents about avoiding based
on her developmental level?
Answer: Provide gates so Julia does not crawl to places where a fall could occur. Keep the
Poison Control number by the phone, and keep poisons and medicines locked. Always use a
properly fitted car seat, and make sure Julia is not able to remove her own seat belt.
3. What is a suggestion you can give the parents about dealing with a child like Julia who
has a shy or slow-to-warm-up temperament?
Answer: Suggest that they let Julia adapt to new environments slowly. Introduce her to new
people by having the parents remain present at first. After several sessions, the parents can leave
for a short time and then return.
Chapter 5: Pediatric Assessment
It is a relatively calm night in the children's hospital Emergency Department when a 6-month-old
infant named Colby is brought in by emergency personnel from an automobile accident. Colby
was in his infant, rear-facing car seat, riding with his parents, when another car rear-ended them.
The parents were not hurt, and did not need to go to the hospital. The father immediately called
911 on his cell phone after the accident. When the ambulance arrived at the Emergency
Department, you were given the report from the EMT. He stated that Colby was alert and quiet
in his father's arms when they arrived on the scene, and he did not have any obvious signs of
trauma. He is being brought to the hospital to make sure he did not sustain any injuries from the
accident. His vital signs are as follows: temperature 98.9ºF, respirations 32, pulse 110, and blood
pressure 85/39. Colby is alert, quiet in his mother's arms, and in with no apparent distress. His
pupils are equal, round, and reactive to light. His anterior fontanel is flat, and he has equal
movements of extremities. His breath sounds are clear and equal bilaterally. His heart sounds
have a regular rate and rhythm without murmur. He voided around 2 hours ago, before the
accident.

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Answers to Clinical Reasoning in Action Scenarios and Questions, in
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
1. The fontanels are an extremely important body part to examine in children. In the
scenario with Colby, they can give an indication if there is increased intracranial
pressure related to a brain injury. Describe the placement of the fontanels, and when
they should close and no longer be palpated. Why is the head more likely to sustain
injury in an infant like Colby versus an adult?
Answer: Infants have a posterior fontanel located between the sagittal suture and lambdoid
suture, and it should close by 3 months old. The anterior fontanel is located between the coronal
suture and sagittal suture, and usually will close by 18 months old. The head is proportionately
larger than that of an adult, and the neck muscles are less able to support the head.
2. After reviewing the scenario, what can you tell the parents about Colby's vital signs at
this time? What is the difference between adult vital signs and Colby's vital signs?
Answer: They can be told that based on Colby's vital signs, everything appears normal and stable
at this time. The heart rate is faster in infants due to their higher metabolic rate and cardiac
output being rate-dependent, not stroke-dependent. The normal heart rate in Colby's age group is
80–130 beats per minute, and the normal heart rate for adults is 60–100 beats per minute. The
respiratory rate is faster in infants due to their higher metabolic rate and proportionately greater
need for oxygen. The normal respiratory rate for an infant is 30–60 breaths per minute, and
gradually decreases into adulthood to 12–20 breaths per minute. The normal blood pressure for
children varies based on their age and height.
3. Describe what structures in the chest and abdominal area of Colby's body would be of
concern after being in this automobile crash.
Answer: The spleen, liver, and lungs would be the main structures of concern with Colby. The
spleen and liver can be traumatized easily due to a lack of much protection by an infant's ribs and
abdomen. The ribs are mostly cartilage at this age, and do not easily fracture. However, forces
from a severe crash can be transmitted to the lung tissue under the ribs and cause bruising or a
pneumothorax. The infant car seat has a 5-point harness to help spread forces from a crash over
the chest and abdomen and help protect the chest and abdomen.
4. If a heart murmur were to be found on examination of Colby, what would be the five
ways to describe it?
Answer: The heart murmur should be described by intensity, location, whether it radiates, when
it occurs (timing), and quality of the sound.
Chapter 6: Introduction to Health Promotion and Maintenance
Six-month-old Sahil is brought to the clinic by his mother, Clarisse, and his grandmother, who
just moved into the home to help Clarisse. Sahil's father recently left the country on a prolonged
work assignment. Clarisse is very anxious about being the main adult responsible for Sahil since
her husband's departure. As you assess Sahil, you find that he is smiling readily, is able to sit on

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Answers to Clinical Reasoning in Action Scenarios and Questions, in
Ball, Bindler and Cowen: Principles of Pediatric Nursing: Caring for Children, 6th Edition
his own with little support, and has length and weight at the 50th percentiles. His mother tells
you that she is breastfeeding and has been feeding Sahil some table food such as rice and tofu.
She has returned to work full-time, so the grandmother will provide care during the day while
Clarisse is at work. You review the immunization record and find that several immunizations are
due at today's visit.
1. As Clarisse returns to work, Sahil will likely be consuming less breast milk and have
more table foods and formula added to his diet. What questions will you ask Clarisse and
Sahil's grandmother to evaluate their knowledge of dietary recommendations for infants?
Answer: Inquire about the type and amount of formula Sahil will be fed, keeping in mind that he
needs formula supplemented with iron. Ask about what foods the family plans to provide for
Sahil, and provide needed instruction about introducing foods to the infant.
2. What immunizations are generally needed for 6-month-old infants, and when should
Sahil return for his next immunizations?
Answer: Sahil needs the third rotavirus, DTaP, HIB, and PCV vaccines. If it is the fall or winter
of the year, and the current year's influenza vaccine is available, he should receive that vaccine.
The third hepatitis B and polio vaccines may be given between 6 and 18 months, dependent on
the practice in the health care office. Sahil should return for his next visit at 12 months of age.
3. You have identified that Clarisse needs support and socialization with other young
mothers to gain confidence in her parenting skills. How will you locate community
resources that are helpful to young families? Decide what parenting information would be
helpful to build Clarisse’s confidence in caring for Sahil without her husband present.
Suggest some ways that she, Sahil, and the father can communicate with each other
regularly.
Answer: Community agencies often support young parents. Explore the YMCA, YWCA,
children's hospitals, pediatric clinics, health maintenance organizations, community colleges,
school districts, child care centers, the local health department, and similar community resources.
4. The major health problem for infants is related to safety hazards. Sahil is becoming
more mobile and curious. Write a teaching plan that includes topics and specific teaching
requirements at his age.
Answer: Have the infant car seat examined at an approved inspection station, do not leave Sahil
on high surfaces such as counters or beds, check the temperature of bath water to avoid burning,
never leave Sahil unattended in a bath or near even a small amount of water, keep medicines and
other harmful substances locked and out of reach, place Sahil on his back for sleeping, and use
only toys appropriate for his age. Both Clarisse and her mother should attend a class for airway
obstruction and cardiopulmonary resuscitation.
Chapter 7: Health Promotion and Maintenance for the Newborn and Infant

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