Test bank for Wong's Nursing Care of Infants and Children 11th Edition by Hockenberry

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Wong's Nursing Care of Infants and Children 11th Edition Hockenberry Test Bank Chapter 1.Perspectives of Pediatric Nursing MULTIPLE CHOICE 1. The clinic nurse is reviewing statistics on inf... ant mortality for the United States versus other countries. Compared with other countries that have a population of at least 25 million, the nurse makes which determination? a. The United States is ranked last among 27 countries. b. The United States is ranked similar to 20 other developed countries. c. The United States is ranked in the middle of 20 other developed countries. d. The United States is ranked highest among 27 other industrialized countries. ANS: A Although the death rate has decreased, the United States still ranks last in infant mortality among nations with a population of at least 25 million. The United States has the highest infant death rate of developed nations. DIF: Cognitive Level: Remembering REF: MCS: 6 TOP: Nursing Process: Assessment iMenStC: Cl Needs: Health Promotion and Maintenance 2. hWich is the leading cause of death in infants younger than 1 year in the United States? a. Congenital anomalies b. Sudden infant death syndrome c. Disorders related to short gestation and low birth weight d. Maternal complications specific to the perinatal period ANS: A Congenital anomalies account for 20.1% of deaths in infants younger than 1 year compared with sudden infant death syndrome, which accounts for 8.2%; disorders related to short gestation and unspecified low birth weight, which account for 16.5%; and maternal complications such as infections specific to the perinatal period, which account for 6.1% of deaths in infants younger than 1 year of age. DIF: Cognitive Level: Remembering REF: MCS: 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. What is the major cause of death for children older than 1 year in the United States? a. Heart disease b. Childhood cancer c. Unintentional injuries d. Congenital anomalies ANS: C Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. The leading cause of death for those younger than 1 year is congenital anomalies, and childhood cancers and heart disease cause a significantly lower percentage of deaths in children older than 1 year of age. DIF: Cognitive Level: Understanding REF: MCS: 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 4. In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years? a. Suicide and cancer b. Suicide and homicide c. Drowning and cancer d. Homicide and heart disease ANS: B Suicide and choumnitcide ac for 16.7% of deaths in this age group. Suicide and cancer account for 10.9% of deaths, heart disease and cancer account for approximately 5.5%, and homicide and heart disease account for 10.9% of the deaths in this age group. DIF: Cognitive Level: Remembering REF: MCS: 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is planning a teaching session to adolescents about hdseabty un intentional injuries. Which should the nurse include in the session with regard to deaths caused by injuries? a. More deaths occur in males. b. More deaths occur in females. c. The pattern of deaths does not vary according to age and sex. d. The pattern of deaths does not vary widely among different ethnic groups. ANS: A The majority of deaths from unintentional injuries occur in males. The pattern of death does vary greatly among different ethnic groups, and the causes of unintentional deaths vary with age and gender. DIF: Cognitive Level: Applying REF: pp. 7-8 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. What do mortality statistics describe? a. Disease occurring regularly within a geographic location b. The number of individuals who have died over a specific period c. The prevalence of specific illness in the population at a particular time d. Disease occurring in more than the number of edxpcect ases in a community ANS: B Mortality statistics refer to the number of individuals who have died over a specific period. Morbidity statistics show the prevalence of specific illness in the population at a particular time. Data regarding disease within a geographic region, or in greater than expected numbers in a community, may be extrapolated from analyzing the morbidity statistics. DIF: Cognitive Level: Remembering REF: MCS: 3 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 7. The nurse should assess which age group for suicide ideation since suicide in which age group is the third leading ecaoufs death? a. Preschoolers b. Young school age c. Middle school age d. Late school age and adolescents ANS: D Suicide is the third leading cause of death in children ages 10 to 19 years; therefore, the age group should be late school age and adolescents. Suicide is not one of the leading causes of death for preschool and young or middle school-aged children. DIF: Cognitive Level: Understanding REF: MCS: 6 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 8. Parents of a hospitalized toddler ask the nurse, What is meant by family-centered care? The nurse should respond with which statement? a. Family-centered care reduces the effect of cultural diversity ofnamthiely. b. Family-centered care encourages family dependence on the health care system. c. Family-centered care recognizes that the family is the constant in a childs life. d. Family-centered care avoids expecting families to be part of the decision-making process. ANS: C The three key components of family-centered care are respect, collaboration, and support. Family-centered care recognizes the family as the constant in tchheilds life. T he family should be enabled and empowered to work with the health care system and is expected to be part of the decision-making process. The nurse should also support the familys cultural diversity, not reduce its effect. DIF: Cognitive Level: Applying REF: MCS: 8 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning? a. Purposeful and goal directed b. A simple developmental process c. Based on deliberate and irrational thought d. Assists individuals in guessing what is most appropriate ANS: A Clinical reasoning is a complex developmental process based on rational and deliberate thought. When thinking is clear, precise, accurate, relevant, consistent, and fair, a logical connection develops between the elements of thought and the problem at hand. DIF: Cognitive Level: Applying REF: MCS: 12 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. Evidence-based practice (EBP), a decision-making model, is best described as which? a. Using information in textbooks to guide care b. Combining knowledge with clinical experience and intuition c. Using a professional code of ethics as a means for decision making d. Gathering all evidence that applies to the childs health and family situation ANS: B EBP helps focus on measurable outcomes; the use of demonstrated, effective interventions; and questioning what is the best approach. EBP involves decision making based on data, not all evidence on a particular situation, and involves the latest available data. Nurses can use textbooks to determine areas of concern and potential involvement. DIF: Cognitive Level: Remembering REF: MCS: 11 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 11. Which best describes signs and symptoms as part of a nursing diagnosis? a. Description of potential risk factors b. Identification of actual health problems c. Human response to state of illness or health d. Cues and clusters derived from patient assessment ANS: D Signs and symptoms are the cues and clusters of defining characteristics that are derived from a patient assessment and indicate actual health problems. The first part of the nursing diagnosis is the problem statement, also known as the human response to the state of illness or health. The identification of actual health problems may be part of the medical diagnosis. The nursing diagnosis is based on the human response to these problems. The human response is therefore a component of the nursing diagnostic statement. Potential risk factors are used to identify nursing care needs to avoid the development of an actual health problem when a potential one exists. DIF: Cognitive Level: Understanding REF: MCS: 13 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment 12. The nurse is talking to a group of parents of school-age children at an after-school program about childhood health problems. Which statement should the nurse include in the teaching? a. Childhood obesity is the most common nutritional problem among children. b. Immunization rates are the same among children of different races and ethnicity. c. Dental caries is not a problem commonly seen in children since the introduction of fluoridated water. d. Mental health problems are typically not seen in school-age children but may be diagnosed in adolescents. ANS: A When teaching epnarts of sch ool-age children about childhood health problems, the nurse should include information about childhood obesity because it is the most common problem among children and is associated with type 2 diabetes. Teaching parents about ways to prevent obesity is important to include. Immunization rates differ depending on the childs race and ethnicity; dental caries continues to be a common chronic disease in childhood; and mental health problems are seen in children as young as school age, not just in adolescents. DIF: Cognitive Level: Applying REF: MCS: 3 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 13. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care? a. Limit explanation of procedures because the child is preschool aged. b. Ask that all family members leave the room when performing procedures. c. Allow the child to choose the type of juice to drink with the administration of oral medications. d. Explain that EMLA cream cannot be used for the morning lab draw because there is not time for it to be effective. ANS: C The overriding goal in providing atraumatic care is first, do no harm. Allowing the child a choice of juice to drink when taking oral medications provides the child with a sense of control. The preschool child should be prepared before procedures, so limiting explanations of procedures would increase anxiety. The family should be allowed to stay with the child during procedures, minimizing stress. Lidocaine/prilocaine (EMLA) cream is a topical local anesthetic. The nurse should plan to use the prescribed cream in time for morning laboratory draws to minimize pain. DIF: Cognitive Level: Applying REF: pp. 8-9 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 14. Which situation denotes a nontherapeutic nursepatientfamily relationship? a. The nurse is planning to read a favorite fairy tale to a patient. b. During shift report, the nurse is criticizing parents for not visiting their child. c. The nurse is discussing with a fellow nurse the emotional draw to a certain patient. d. The nurse is working with a family to find ways to decrease the familys dependence on health care providers. ANS: B Criticizing parents for not visiting in shift report is nontherapeutic and shows an underinvolvement with the parents. Reading a fairy tale is a therapeutic and age appropriate action. Discussing feelings of an emotional draw with a fellow nurse is therapeutic and shows a willingness to understand feelings. Working with parents to decrease dependence on health care providers is therapeutic and helps to empower the family. DIF: Cognitive Level: Analyzing REF: MCS: 9 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 15. The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking? a. Preschool b. Young school age c. Middle school age d. Adolescent ANS: A Preschool children have the cognitive characteristic of magical and egocentric thinking, meaning they are unable to comprehend danger to self or others. Young and middle school-aged children have transitional cognitive processes, and they may attempt dangerous acts without detailed planning but recognize danger to themselves or others. Adolescents have formal operational cognitive processes and are preoccupied with abstract thinking. DIF: Cognitive Level: Understanding REF: MCS: 4 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 16. The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury? a. Female, multiple siblings, stable home life b. Male, high activity level, stressful home life c. Male, even tempered, history of previous injuries d. Female, reacts negatively to new situations, no serious previous injuries ANS: B Boys have a preponderance for injuries over girls because of a difference in behavioral characteristics, a high taicvity t emperament sisocaisated w ith risk-taking behaviors, and stress predisposes children to increased risk taking and self-destructive behaviors. Therefore, a male child with a high activity level and living in a stressful environment has the highest number of risk factors. A girl with several siblings and a stable home life is low risk. A boy with vpiroeus injuries has two risk factors, but an even temper is not a risk factor for injuries. A girl who reacts negatively to new situations but has no previous serious illnesses has only one risk factor. DIF: Cognitive Level: Analyzing REF: MCS: 4 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 17. The school unautrisnegistheeval number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which? a. 50th percentile b. 75th percentile c. 80th percentile d. 95th percentile ANS: D Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender. DIF: Cognitive Level: Remembering REF: MCS: 3 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 18. The nurse is teaching parents about the types of behaviors children exhibit when living with chronic violence. Which statement made by the parents indicates further teaching is needed? a. We should watch for aggressive play. b. Our child may show lasting symptoms of stress. c. We know that our child will show caring behaviors. d. Our child may have difficulty concentrating in school. ANS: C The statement that the child will show caring behaviors needs further teaching. Children living with chronic violence may exhibit behaviors such as difficulty concentrating in school, memory impairment, aggressive play, uncaring behaviors, and lasting symptoms of stress. DIF: Cognitive Level: Applying REF: MCS: 6 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is evaluating research studies according to the GRADE criteria and has determined the quality of evidence on the subject is moderate. Which type of evidence does this determination indicate? a. Strong evidence from unbiased observational studies b. Evidence from randomized clinical trials showed inconsistent results c. Consistent evidence from well-performed randomized clinical trials d. Evidence for at least one critical outcome from randomized clinical trials had serious flaws ANS: B Evidence from randomized clinical trials with important limitations indicates that the evidence is of moderate quality. Strong evidence from unbiased observational studies and consistent evidence from well-performed randomized clinical trials indicates high quality. Evidence for at least one ictrical outcome f rom randomizediclailntrials th at has serious wflas indi cates low quality. DIF: Cognitive Level: Remembering REF: MCS: 12 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 20. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions? a. Justice b. Autonomy c. Beneficence d. Nonmaleficence ANS: B Autonomy is the patients right to be self-governing. The adolescent is trying to be autonomous, so the nurse is supporting this value. tJhuestice is concept of fairness. Beneficence is the obligation to optreomthe pa tients well-being. Nonmaleficence is the obligation to minimize or prevent harm. DIF: Cognitive Level: Analyzing REF: MCS: 11 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 21. The nurse manager is compiling a report for a hospital committee on the quality of nursing- sensitive indicators for a nursing unit. Which does the nurse manager include in the report? a. The average age of the nurses on the unit b. The salary ranges for the nurses on the unit c. The education and certification of the nurses on the unit d. The number of nurses who have applied but were not hired for the unit ANS: C Nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care. For example, the number of nursing staff, the skill level of the nursing staff, and the education and certification of nursing staff indicate the structure of nursing care. The average age of the nurses, salary range, and number of nurses who have applied but were not hired for the unit are not nursing-sensitive indicators. DIF: Cognitive Level: Applying REF: MCS: 15 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which responsibilities are included in the pediatric nurses promotion of the health and well- being of children? (Select all that apply.) a. Promoting disease prevention b. Providing financial assistance c. Providing support and counseling d. Establishing lifelong friendships e. Establishing a therapeutic relationship f. Participating in ethical decision making ANS: A, C, E, F The pediatric nurses role includes promoting disease prevention, providing support and counseling, establishing a therapeutic relationship, and participating in ethical decision making; a pediatric nurse does not need to establish lifelong friendships or provide financial assistance to children and their families. Boundaries should be set and clear. DIF: Cognitive Level: Applying REF: pp. 9-11 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 2. The nurse is conducting a teaching session for parents on nutrition. Which characteristics of families should the nurse consider that can cause families to struggle in providing adequate nutrition? (Select all that apply.) a. Homelessness b. Lower income c. Migrant status d. Working parents e. Single parent status ANS: A, B, C Families that struggle with lower incomes, homelessness, and migrant asttus generally lack the resources to provide their children with adequate food intake, nutritious foods such as fresh fruits and vegetables, and appropriate protein intake. Working parents and single parent status do not mean the families will struggle to provide adequate nutrition. DIF: Cognitive Level: Applying REF: MCS: 2 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. The nurse is preparing to complete documentation on a patients chart. Which should be included in documentation of nursing care? (Select all that apply.) a. Reassessments b. Incident reports c. Initial assessments d. Nursing care provided e. Patients response of care provided ANS: A, C, D, E The patients medical record shouldliundce: initial asse ssments, reassessments, ngursi care provided, and the patients response of care provided. Incident reports are not documented in the patients chart. DIF: Cognitive Level: Applying REF: MCS: 14 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment 4. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.) a. Buying clothes for the patients b. Showing favoritism toward a patient c. Focusing on technical aspects of care d. Spending off-duty time with patients and families e. Asking questions if families are not participating in care ANS: A, B, D Actions that show overinvolvement include buying clothes for patients, showing favoritism toward a patient, and spending off-duty time with patients and families. Focusing on technical aspects of care is an action that indicates underinvolvement, and asking questions if families are not participating in care indicates a positive action. DIF: Cognitive Level: Analyzing REF: pp. 9-10 TOP: Integrated Process: Caring MSC: Client Needs: Health Promotion and Maintenance 5. Which are included in the evaluation step of the nursing process? (Select all that apply.) a. Determination if the outcome has been met b. Ascertaining if the plan requires modification c. Establish priorities and selecting expected patient goals d. Selecting alternative interventions if the outcome has not been met e. Determining if a risk or actual dysfunctional health problem exists ANS: A, B, D Evaluation is the last step in the nursing process. The nurse gathers, sorts, and analyzes data to determine whether (1) the established outcome has been met, (2) tnhuersing interventions were appropriate, (3) the plan requires modification, or (4) other alternatives should be considered. Establishing priorities and selecting expected patient goals are done in the outcomes identification stage. Determining if a risk or actual dysfunctional health problem exists is done in the diagnosis stage of the nursing process. DIF: Cognitive Level: Understanding REF: MCS: 14 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 6. Which should the nurse teach to parents regarding oral health of children? (Select all that apply.) a. Fluoridated water should be used. b. Early childhood caries is a preventable disease. c. Dental caries is a rare chronic disease of childhood. d. Dental hygiene should begin with the first tooth eruption. e. Childhood caries does not happen until after 2 years of age. ANS: A, B, D Oral health instructions to parents of children should include use of fluoridated water and dental hygiene beginning with the first tooth eruption. In addition, early childhood caries is a preventable disease and should be included in the teaching session. Dental caries is a common, not rare, chronic disease of childhood. Childhood caries may begin before the first birthday. DIF: Cognitive Level: Applying REF: MCS: 2 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 7. The school nurse is explaining to older school children that obesity increases the risk for which disorders? (Select all that apply.) a. Asthma b. Hypertension c. Dyslipidemia d. Irritable bowel disease e. Altered glucose metabolism ANS: B, C, E Overweight youth have increased risk for a cluster of cardiovascular factors that include hypertension, altered glucose metabolism,iapniddedmyisal. I rritable bowel disease and asthm are not linked to obesity. DIF: Cognitive Level: Applying REF: MCS: 3 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading healthaitnodrisc? (Select all that apply.) a. Decrease tobacco use. b. Improve immunization rates. c. Reduce incidences of cancer. d. Increase access to health care. e. Decrease the number of eating disorders. ANS: A, B, D The Healthy People 2020 leading health indicators provide a framework for identifying seesntial components for child health promotion programs designed to prevent future health problems in our nations children. Some of the leading health indicators include decreasing tobacco use, improving immunization rates, and increasing access to health care. Reducing the incidence of cancer and decreasing the number of eating disorders are not olnisthae indicators. s ltheading heal DIF: Cognitive Level: Analyzing REF: MCS: 2 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 9. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.) a. Basing decisions on intuition b. Considering alternative action c. Using formal and informal thinking to gather data d. Giving deliberate thought to a patients problem e. Developing an outcome focused on optimum patient care ANS: B, C, D, E Clinical reasoning is a cognitive process that uses formal and informal thinking to gather and analyze patient data, evaluate the significance of the information, and consider alternative actions. Clinical reasoning is a complex developmental process based on rational and deliberate thought and developing an outcome focused on optimum patient care. Clinical reasoning is based on the scientific method of inquiry; it is not based solely on intuition. Chapter 2.Social, Cultural, Religious, and Family Influences on Child Health Promotion MULTIPLE CHOICE 1. Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which factor may be culturally determined? a. Ethnicity b. Racial variation c. Status d. Geographic boundaries ANS: C Status is culturally determined and varies according to each culture. Some cultures ascribe higher status to age or socioeconomic position. Social roles also are influenced by the culture. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. It is one component of culture. Race and culture are two distinct attributes. Whereas racial grouping describes transmissible traits, culture is determined by the pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. Cultural development may be limited by geographic boundaries, but the boundaries are not culturally determined. DIF: Cognitive Level: Analyzing REF: MCS: 39 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: 2P.syTchheonsoucrsiaeliIsnatwegarrietythat if patients different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what? a. Acculturation b. Ethnocentrism c. Cultural shock d. Cultural sensitivity ANS: B Ethnocentrism is the belief that ones way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of ones ethnic group are superior to those of others. Acculturation is the gradual changes that are produced in a culture by the influence of another culture that cause one or both cultures to become more similar. The minority culture is forced to learn the majority culture to survive. Cultural shock is the helpless feeling and state of disorientation felt by an outsider attempting to adapt to a different culture group. Cultural sensitivity, a component of culturally competent care, is an awareness of cultural similarities and differences. DIF: Cognitive Level: Understanding REF: MCS: 35 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Itengrity 3. Which term best describes the sharing of common characteristics that fdeifrentiate s one group from other groups in a society? a. Race b. Culture c. Ethnicity d. Superiority ANS: C Ethnicity is a classification aimed at grouping individuals who consider themselves, or are considered by others, to share common characteristics that differentiate them ofrm t he other collectivities in a society, and from which they develop their distinctive cultural behavior. Race is a term that groups together people by their outward physical appearance. Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that serve as a frame of ererfence for individual perception and judgments. Superiority is the state or quality of being superior; it does not apply to ethnicity. DIF: Cognitive Level: Understanding REF: MCS: 39 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. After the family, which has the greatest influence on providing continuity between generations? a. Race b. School c. Social class d. Government ANS: B Schools convey a tremendous amount of culture from the older members to the younger membersocoifetsy. They prepare children to carry oeutrt th aditional social roles that will be expected of them as adults.sRdaecfeinied as a division of humankind possessing traits that are transmissible by descent and are sufficient torcahcaterize race as a distinct hum an type; although race may have an influence on childrearing practices, its role is not as significant hasa t of schools. Social class refers to ethfamilys economic and educational levels. The social class of a family may change between generations. The government iesshtaebslparameters for children, including amount of schooling, but this is usually at a local level. The school culture has the most significant influence on continuity besides family. DIF: Cognitive Level: Remembering REF: MCS: 33 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 5. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal? a. Adapt, as necessary, ethnic practices to health needs. b. Attempt, in a nonjudgmental way, to change ethnic beliefs. c. Encourage continuation of ethnic practices in the hospital setting. d. Strive to keep ethnic background from influencing health needs. ANS: A Whenever possible, nurses should facilitate the integration of ethnic practices into health care provision. The ethnic background is part of the individual; it should be difficult to eliminate the influence of ethnic background. The ethnic practices need to be evaluated within the context of the health care setting to determine whether they are conflicting. DIF: Cognitive Level: Applying REF: MCS: 34 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Itengrity 6. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The childs mother says she has rubbed the edge of a coin on her childs oiled skin. The nurse should recognize this as what? a. Child abuse b. Cultural practice to rid the body of disease c. Cultural practice to treat enuresis or temper tantrums d. Child discipline measure common in the Vietnamese culture ANS: B This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the childs oiled skin. The mother is attempting to rid the childs body of disease. Coining is a cultural healing practice. Coining is not specific for enuresis or temper tantrums. This is not child abuse or discipline. DIF: Cognitive Level: Understanding REF: MCS: 41 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 7. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this? a. The parent is trying to feed the child only what the child likes most. b. Hispanics believe the evil eye enters when a person gets cold. c. The parent is trying to restore normal balance through appropriate hot remedies. d. Hispanics believe an innate energy called chi is strengthened by eating soup. ANS: C In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe certain properties completely eulnarted to t permature. R espiratory conditions such as pneumonia are cold conditions and are treated with hot foods. The child may like broth but is unlikely to alyws fperre it to lJl-eO , Popsicles, and juice. The evil eye applies to a state of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe in chi as an innate energy. DIF: Cognitive Level: Applying REF: MCS: 40 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 8. How aismfily systems theory be st described? a. The family is viewed as the sum of individual members. b. A change in one family member cannot create a change in other members. c. Individual family members are readily identified as the source of a problem. d. When the family system is disrupted, change can occur at any point in the system. ANS: D Family systems theory describes an interactional model. Any change in one member will create change in others. Although the family is the sum of the individual members, family systems theory focuses on the number of dyad interactions that can occur. The interactions, not the individual members, are considered to be the problem. DIF: Cognitive Level: Analyzing REF: MCS: 18 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 9. Which family theory is described as a series of tasks for the family throughout its life span? a. Exchange theory b. Developmental theory c. Structural-functional theory d. Symbolic interactional theory ANS: B In developmental systems theory, the family is described as a small group, a semiclosedesmyst of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. Exchange theory assumes that humans, families, and groups seek rewarding statuses so that arerwds are maximizedewchoislts are minimized. Structural-functional theory states that the family performs at least one iseotcal function w hile also meeting family needs. Symbolic interactional theory describes the family as a unit of interacting persons with each occupying a position within the family. DIF: Cognitive Level: Remembering REF: MCS: 19 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 10. Which family theory explains how families react to estsrsful eve nts and suggests factors that promote adaptation to these events? a. Interactional theory b. Family stress theory c. Eriksons psychosocial theory d. Developmental systems theory ANS: B Family stress theory explains the reaction of families to stressful events. In addition, the theory helps suggest factors that promote adaptation to the stress. Stressors, both positive and negative, are cumulative and affect the family. Adaptation requires a change in family structure or interaction. Interactional theory is not a mfaily thye. or Interactions are the basis of egreanl systems theory. Eriksons theory applies to individual growth and development, not families. Developmental systems theory is an outgrowth of Duvalls theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. DIF: Cognitive Level: Remembering REF: MCS: 19 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity 11. Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together? a. Blended b. Nuclear c. Extended d. Binuclear ANS: C An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. A blended family contains at least one stepparent, stepsibling, or half-sibling. A nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. DIF: Cognitive Level: Remembering REF: pp. 20-21 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. Which type of family should the nurse recognize when a mother, her children, and a stepfather live together? a. Traditional nuclear b. Blended c. Extended d. Binuclear ANS: B A blended family contains at least one stepparent, stepsibling, or half-sibling. A traditional nuclearifsatsmoily cons f a married ceoaupl irnbdiothloegic children. No other relatives or nonrelatives are present in the household. An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. DIF: Cognitive Level: Remembering REF: MCS: 20 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 13. Which is an accurate description of homosexual (or egsabyi-aln) f amilies? a. A nurturing environment is lacking. b. The children become homosexual like their parents. c. The stability needed to raise healthy children is lacking. d. The quality of parenting is equivalent to that of nongay parents. ANS: D Although gay or lesbian families may be different from heterosexual families, the environment can be as healthy as any other. Lacking a nurturing environment and stability is reflective on the parents and family, not the type of family. There is little evidence to support that children become homosexual like their parents. DIF: Cognitive Level: Understanding REF: pp. 21-22 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 14. The nurse is teaching a group of new nursing graduates about identifiable qualities of strong families that help them function effectively. Which quality should be included in the teaching? a. Lack of congruence among family members b. Clear set of family values, rules, and beliefs c. Adoption of one coping strategy that always promotes positive functioning in dealing with life events d. Sense of commitment toward growth of individual family members as opposed to that of the family unit ANS: B A clear set of family rules, values, and beliefs that establish expectations about abccleepatnd desired behavior is one of the qualities of strong families that help them function effectively. Strong families have a sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs. Varied coping strategies are used by strong families. The sense of commitment oiswtard t he growth andlwel -being of individual family members, as well as the family unit. DIF: Cognitive Level: Applying REF: MCS: 22 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 15. When assessing a mfaily, the enudres termines that the rpa ents exert little or no control over their children. This sletyof parenting is called which? a. Permissive b. Dictatorial c. Democratic d. Authoritarian ANS: A Permissive parents avoid imposing their own standards of conduct and allow their children to regulate theirtoivwitny ac s mh auc s possible. The parents exert little or no control over their childrens actions. Dictatorial or authoritarian parents attempt to control their childrens behavior and attitudes through unquestioned mandates. They establish rules and regulations or standards of conduct that they expect to be followed rigidly and unquestioningly. Democratic parents combine ipsesrimve and dictatorial styles. Theycdtitrheeir childrens behavior and attitudes by emphasizing the reasons for rules and negatively reinforcing deviations. They respect their childrens individual natures. DIF: Cognitive Level: Remembering REF: MCS: 24 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 16. When discussing discipline with the mother of a 4-year-old child, which should the nurse include? a. Parental control should be consistent. b. Withdrawal of love and approval is effective at this age. c. Children as young as 4 years rarely need to be disciplined. d. One should expect rules to be followed rigidly and unquestioningly. ANS: A For effective discipline, parents must be consistent and must follow through with agreed-on actions. Withdrawal of love and approval is never appropriate or ecfftive. T he 4-year-old child will test limits and may misbehave. Children of this age do not respond to verbal reasoning. Realistic goals should be set for itsh age group. Discipline is necessary tonrfeoirce these goals. Discipline strategies should be appropriate to the childs age and temperament and the severity of the misbehavior. Following rules rigidly and unquestioningly is beyond the developmental capabilities of a 4-year-old child. DIF: Cognitive Level: Applying REF: MCS: 24 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 17. Which is a consequence of the physical punishment of children, such as spanking? a. The psychologic impact is usually minimal. b. The childs development of reasoning increases. c. Children rarely become accustomed to spanking. d. Misbehavior is likely to occur when parents are not present. ANS: D Through the use of physical punishment, children learn what they should not do. When parents are not around, it is more likely that children will misbehave because they have not learned to behave well for their own sake but rather out of fear of punishment. Spanking can cause severe physical and psychologic injury and interfere with effective parentchild interaction. The use of corporal punishment may interfere with the childs development of moral reasoning. Children do become accustomed to spanking, requiring more severe corporal punishment each time. DIF: Cognitive Level: Analyzing REF: MCS: 26 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: P18sy. cThhoesopcairaelnItsntoefgarityyoung child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include? a. Send the child to his or her room if the child has one. b. A general rule for length of time is 1 hour per year of age. c. Select an area that is safe and nonstimulating, such as a hallway. d. If the child cries, refuses, or is more disruptive, try another approach. ANS: C The area must be nonstimulating and safe. The child becomes bored in this environment and then changes behavior to rejoin activities. The childs room may have toys and activities that negate the effect of being separated from the family. The general rule is 1 minute per year of age. An hour per year is excessive. When the child cries, refuses, or is more disruptive, the time-out does not start; the time-out begins when the child quiets. DIF: Cognitive Level: Remembering REF: MCS: 26 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 19. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response? a. It is best to wait until the child asks about it. b. The best time to tell the child is between the ages of 7 and 10 years. c. It is not necessary to tell a child who was adopted so young. d. Telling the child is an important aspect of their parental responsibilities. ANS: D It is important for the parents not to withhold information about the adoption from the child. It is an essential component of the childs identity. There is no recommended best time to tell children. It is believed that children should be told young enough so they do not remember a time when they did not know. It should be done before the children enter school to prevent third parties from telling the children before the parents have had the opportunity. DIF: Cognitive Level: Analyzing REF: MCS: 27 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 20. Children may believe that they are responsible for their parents divorce and interpret the separation as punishment. At which age is this most likely to occur? a. 1 year b. 4 years c. 8 years d. 13 years ANS: B Preschool-age children are most likely to blame themselves for tdhievorce. A 4 -year-old child will fear abandonment and express bewilderment regarding all human relationships. A 4-year-old child has magical thinking and believes his or her actions cause consequences, such as divorce. For infants, divorce may increase their irritability and interfere with the attachment process, but they are too young to feel responsibility. School-age children will have feelings of deprivation, including the loss of a parent, attention, money, and a secure future. Adolescents are able to disengage themselves from the parental conflict. DIF: Cognitive Level: Analyzing REF: MCS: 29 TOP: Nursing Process: Planning MSC: Client cNheoesdosc:iPalsyI ntegrity 21. A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what? a. Indicative of maladjustment b. A common reaction to divorce c. Suggestive of a lack of adequate parenting d. An unusual response that indicates a need for referral ANS: B Parental divorce affects school-age children in many ways. In addition to difficulties in school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of appetite, and sleep disorders. The childs responses are common reactions of school-age children to parental divorce. DIF: Cognitive Level: Applying REF: MCS: 29 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 22. A mother brings 6-month-old Eric to the caliwnic for ell-baby checkup. She comments, I want to go back to work, but I dont want Eric to suffer because Ill have less time with him. Which is the nurses most appropriate answer? a. Im sure hell be fine if you get a good babysitter. b. You will need to stay home until Eric starts school. c. Lets talk about the child care options that will be best for Eric. d. You should go back to work so Eric will get used to being with others. ANS: C Asking the mother about child care options is an open-ended statement that will assist the mother in exploring her concerns about what is best for both her and Eric. The other three answers are directive; they do not address the effect that her working will have on Eric. DIF: Cognitive Level: Applying REF: MCS: 32 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 23. A fteorsparent is talking to the nurse about the health care needs for tchheild w ho has been placed in the parents care. eWmheincht children? stat best describes the health care needs of tfeors a. Foster children always come from abusive households and are emotionally fragile. b. Foster children tend to have a higher than normal incidence of acute and chronic health problems. c. Foster children are usually born prematurely and require technologically advanced health care. d. Foster children will not stay in the home for an extended period, so health care needs are not as important as emotional fulfillment. ANS: B Children who are placed in foster care have a higher incidence of acute and chronic health problems and may experience feelings of isolation and confusion; therefore, they should be monitored closely. Foster children do not always come from abusive households and may or may not be emotionally fragile; not all foster children are born mpraeturely or require technically advanced health care; and foster children may stay in the home for extended periods, so their health care needs require attention. DIF: Cognitive Level: Applying REF: MCS: 32 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 24. The nurse is planning to counsel family members as a group to assess the familys group dynamics. Which theoretic family model is the nurse using as a framework? a. Feminist theory b. Family stress theory c. Family systems theory d. Developmental theory ANS: C In family systems theory, the family is viewed as a system that continually interacts with its members and the environment. The emphasis is on the interaction between the members; a change in one family member creates a change in other members, which in turn results in a new change in the original member. Assessing the familys group dynamics is an example of using this theory as a framework. Familysstrteh eory aexinpsl how families recat to s stsrfeul events and sufggest actors that promote adaptation torsetss. D evelopmental theory addresses family change over time using lDlsufvaamily l ife cycle stages based on the predictable changes in the familys structure, function, and roles, with the age of the oldest child as the marker for stage transition. Feminist theories assume that privilege and power are inequitably distributed based upon gender, race, and class. DIF: Cognitive Level: Applying REF: MCS: 18 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 25. The enuisrsre viewing the tiamnpcoerof role learning for children. The enuurnsderstands that childrens roles are primaripleydsha by which members? a. Peers b. Parents c. Siblings d. Grandparents ANS: B Childrens roles are shaped primarily by the parents, who apply direct or indirect pressures to induce or force children into the desired patterns of behavior or direct their efforts toward modification of the role responses of the child on a mutually acceptable basis. DIF: Cognitive Level: Analyzing REF: pp. 22-23 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 26. The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group? a. Peers b. Parents c. Siblings d. Teachers ANS: A Adolescents from a large family are more peer oriented than family oriented. Adolescents in small families identify more strongly with their parents and rely more on them for advice. DIF: Cognitive Level: Understanding REF: MCS: 23 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Itengrity 27. The nurse is explaining different parenting styles to a group of parents. The nurse explains that an authoritative parenting style can lead to which child behavior? a. Shyness b. Self-reliance c. Submissiveness d. Self-consciousness ANS: B Children raised by parents with an authoritative parenting style tend to have high self-esteem and are self-reliant, assertive, inquisitive, content, and highly interactive with other children. Children raised by parents with an authoritarian parenting style tend to be sensitive, shy, self- conscious, retiring, and submissive. DIF: Cognitive Level: Applying REF: MCS: 24 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 28. Parents of a preschool child ask the nurse, Should we set rules for our child as part of a discipline plan? Which is an accurate response by the nurse? a. It is best to delay the punishment if a rule is broken. b. The child is too young for rules. At this age, unrestricted freedom is best. c. It is best to set the rules and reason with the child when the rules are broken. d. Set clear and reasonable rules and expect the same behavior regardless of the circumstances. ANS: D Nurses can help parents establish realistic and concrete rules. Tclheearer the limits that ar e set and the more consistently they are enforced, the less need there is for disciplinary action. Delaying punishment weakens its intent. Children want and need limits. Unrestricted freedom is a threat to their security and safety. Reasoning involves explaining why an act is wrong and is usually appropriate for older children, especially when moral issues are involved. However, young children cannot be expected to see the other side because of their egocentrism. DIF: Cognitive Level: Applying REF: MCS: 25 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 29. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed? a. We will try to preserve the adopted childs racial heritage. b. We are glad we will be getting full medical information when we adopt our child. c. We will make sure to have everyone realize this is our child and a member of the family. d. We understand strangers may make thoughtless comments about our child being different from us. ANS: B In international adoptions, the medical information the parents receive may be incomplete or sketchy; weight, height, and head circumference are often the only objective information present in the childs medical record. Further teaching is needed if the parents expect full medical information. It is advised that parents who adopt children with different ethnic backgrounds do everything to preserve the adopted childrens racial heritage. Strangers may make thoughtless comments and talk about the children as though they were not members of the family. It is vital that family members declare to others that this is their child and a cherished member of the family. DIF: Cognitive Level: Applying REF: pp. 27-28 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 30. The school nurse understands that children are impacted by divorce. Which has the most impact on the positive outcome of a divorce? a. Age of the child b. Gender of the child c. Family characteristics d. Ongoing family conflict ANS: C Family characteristics are more crucial to the childs well-being during a divorce than specific child characteristics, such as age or sex. High levels of ongoing family conflict are related to problems of social development, emotional stability, and cognitive skills for the child. DIF: Cognitive Level: Understanding REF: MCS: 29 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 31. The nurse is discussing parenting in reconstituted families with a new stepparent. The nurse is aware that the new stepparent understands the teaching when which statement aisdme? a. Iram glad the e will be no disruption in my lifestyle. b. I dont think children really want to live in a two-parent home. c. I realize there may be power conflicts bringing two households together. d. I understand contact between grandparents should be kept to a minimum. ANS: C The entry of a stepparent into a ready-made family requires adjustments for all family members. Power conflicts are expected, and flexibility, mutual support, and open communication are critical in successful aretilonships. S o tshtaetement thpaower conflicts ar e possible means teaching was understood. Some obstacles to the role adjustments and family problem solving include disruption of previous lifestyles and interaction patterns, complexity in the formation of new ones, and lack of social supports. Most children from divorced families want to live in a two-parent home. There should be continued contact with grandparents. DIF: Cognitive Level: Applying REF: MCS: 31 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Iteng rity MULTIPLE RESPONSE 1. The nurse is presenting a staff development program about understanding culture in the health care encounter. Which components should the nurse include in the program? (Select all that apply.) a. Cultural humility b. Cultural research c. Cultural sensitivity d. Cultural competency ANS: A, C, D There are several different ways health care providers can best attend to all the different facets that make up an individuals culture. Cultural competence tends to promote building information about a specific culture. Cultural sensitivity, a second way of understanding culture in the context of the clinical encounter, may be understood as a way of using ones knowledge, consideration, understanding, respect, and tailoring after realizing awareness of self and others and encountering a diverse group or individual. Cultural humility, the third component, is a commitment and active engagement in a lifelong process that individuals enter into for an ongoing basis with patients, communities, colleagues, and themselves. Cultural research is not a component of understanding culture in the health care encounter. DIF: Cognitive Level: Analyzing REF: MCS: 38 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: P2.syTchheopsoarceianltsInotfeagr5it-yyear-old child ask the nurse how they can minimize misbehavior. Which responses should the nurse give? (Select all that apply.) a. Set clear and reasonable goals. b. Praise your child for desirable behavior. c. Dont call attention to unacceptable behavior. d. Teach desirable behavior through your own example. e. Dont provide an opportunity for your child to have any control. ANS: A, B, D To minimize misbehavior, parents should (1) set clear and reasonable rules and expect the same behavior regardless of the circumstances, (2) apirse children f or desirable behavior with attention and verbal approval, and (3) teach desirable behavior through their own example. Parents should call attention to unacceptable behavior as soon as it begins and provide children with opportunities for power and control. DIF: Cognitive Level: Applying REF: MCS: 25 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 3. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.) a. Regressive behavior b. Fear of abandonment c. Fear regarding the future d. Blame themselves for the divorce e. Intense desire for reconciliation of parents ANS: A, B, D Feelings and behaviors of early preschool children related to divorce include regressive behavior, fear of abandonment, and blaming themselves for the divorce. Fear regarding the future and intense desire for reconciliation of parents is a reaction later school-age children have to divorce. DIF: Cognitive Level: Understanding REF: MCS: 29 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 4. Which describe the feelings and behaviors of adolescents related to divorce? (Select all that apply.) a. Disturbed concept of sexuality b. May withdraw from family and friends c. Worry about themselves, parents, or siblings d. Expression of anger, sadness, shame, or embarrassment e. Engage in fantasy to seek understanding of the divorce ANS: A, B, C, D Feelings and behaviors of adolescents related to divorce include a disturbed concept of sexuality; withdrawing from family and friends; worrying about themselves, parents, and siblings; and expressions of anger, sadness, shame, and embarrassment. Engaging in fantasy to seek understanding of the divorce is a reaction by a child who has preconceptual cognitive processes, not the formal thinking processes adolescents have. Chapter 3.Hereditary Influences on Health Promotion of the Child and Family MULTIPLE CHOICE 1. Which genetic term refers to a person who possesses one copy of an affected gene and one copy of an unaffected gene and is clinically unaffected? a. Allele b. Carrier c. Pedigree d. Multifactorial ANS: B An individual who aisrraiecr is asymptomatic but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expressions of genes at a different locus. A pedigree is a diagram that describes family rlaetionships, ge nder, disease, status, or other relevant information about a family. Multifactorial describes a complexrianctteion of both genetic and environmental factors that produce an effect on the individual. DIF: Cognitive Level: Understanding REF: MCS: 46 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 2. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome afterocmhrosome breakage? a. Trisomy b. Monosomy c. Translocation d. Nondisjunction ANS: C Translocation is the transfer of all or part of a chromosome to a different chromosome after chromosome breakage. It can be balanced, producing no phenotypic effects, or unbalanced, producing severe or lethal effects. Trisomy is an abnormal number of chromosomes caused by the presence of an extra chromosome, which is added to a given chromosome pair and results in a total of 47 chromosomes per cell. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction is the failure of homologous chromosomes or chromatids to separate during mitosis or meiosis. DIF: Cognitive Level: Understanding REF: MCS: 48 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. Which is a birth defect or disorder that occurs as a new case in a family and is not inherited? a. Sporadic b. Polygenic c. Monosomy d. Association ANS: A Sporadic describes a birth defect previously unidentified in a family. It is not inherited. Polygenic inheritance involves the inheritance of many genes at separate loci whose combined effects produce a given phenotype. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. A nonrandom cluster of malformations without a specific cause is an association. DIF: Cognitive Level: Understanding REF: MCS: 48 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. The nurse is assessing a neonate who was born 1 hour ago to healthy white parents in their early forties. Which finding should be most suggestive of Down syndrome? a. Hypertonia b. Low-set ears c. Micrognathia d. Long, thin fingers and toes ANS: B Children with Down syndrome have low-set ears. Infants with Down syndrome have hypotonia, not hypertonia. Micrognathia is common in trisomy 16, not Down syndrome. Children with Down syndrome have short hands with broad fingers. DIF: Cognitive Level: Understanding REF: MCS: 82 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. Which abnormality is a common sex chromosome defect? a. Down syndrome b. Turner syndrome c. Marfan syndrome d. Hemophilia ANS: B Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy 21 (three copies rather than two copies of chromosome 21). Marfan syndrome is a connective tissue disorder inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern. DIF: Cognitive Level: Understanding REF: MCS: 53 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 6. Turner syndrome is suspected in an adolescent girl with short stature. What causes this? a. Absence of one of the X chromosomes b. Presence of an incomplete Y chromosome c. Precocious puberty in an otherwise healthy child d. Excess production of both androgens and estrogens ANS: A Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. These young women have 45 rather than 46 chromosomes. DIF: Cognitive Level: Understanding REF: MCS: 53 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 7. Which is a sex chromosome abnormality that is caused by the presence of one or more additional X chromosomes in a male? a. Turner b. Triple X c. Klinefelter d. Trisomy 13 ANS: C Klinefelter syndrome is characterized by one or more additional X chromosomes. These individuals are tall with male secondary sexual characteristics that may be deficient, and they may be learning disabled. An absence of an X chromosome results in Turner syndrome. Triple X and trisomy 13 are not abnormalities that involve one or more additional X chromosomes in a male (Klinefelter syndrome). DIF: Cognitive Level: Understanding REF: MCS: 53 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Parents ask the nurse about the characteristics of autosomal dominant inheritance. Which statement is characteristic of autosomal dominant inheritance? a. Females are affected with greater frequency than males. b. Unaffected children of affected individuals will have affected children. c. Each child of a heterozygous affected parent has a 50% chance of being affected. d. Any child of two unaffected heterozygous parents has a 25% chance of being affected. ANS: C In autosomal dominant inheritance, only one copy of the mutant gene is necessary tohceause t disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for the disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not skip a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for ethdisorder. I n autosomal recessive inheritance, any child of two unaffected heterozygous parents has a 25% chance of being affected. DIF: Cognitive Level: Applying REF: MCS: 57 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. Parents ask the nurse about the characteristics of autosomal recessive inheritance. Which is characteristic of autosomal recessive inheritance? a. Affected individuals have unaffected parents. b. Affected individuals have one affected parent. c. Affected parents have a 50% chance of having an affected child. d. Affected parents will have unaffected children. ANS: A Parents who are carriers of a recessive gene are asymptomatic. For a child tofbeectaefd, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic but can have affected children. Inoamutaolsrecessive inheritance, ethre is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance, affected parents can have unaffected children. DIF: Cognitive Level: Applying REF: MCS: 62 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Health P romotion and Maintenance 10. Which is characteristic of X-linked recessive inheritance? a. There are no carriers. b. Affected individuals are principally males. c. Affected individuals are principally females. d. Affected individuals will always have affected parents. ANS: B In X-linked recessive disorders, the affected individuals are usually em.aWl ith rveectersasiits, usually two copies of the gene are needed to produce the effect. Because the male only hXas one chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disordXercs. The hromosome that does not have the recessive gene will produce the normal protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected. DIF: Cognitive Level: Understanding REF: MCS: 64 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 11. A fthaer with a n X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. Which response should the nurse make? a. Male children will be carriers. b. All male children will be affected. c. None of the sons will have the disorder. d. It cannot be determined without more data. ANS: C When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes only his Y chromosome (not the X chromosome) to his sons. Therefore, none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question. DIF: Cognitive Level: Applying REF: MCS: 64 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 12. The inheritance of which is X-linked recessive? a. Hemophilia A b. Marfan syndrome c. Neurofibromatosis d. Fragile X syndrome ANS: A Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an X- linked trait. DIF: Cognitive Level: Understanding REF: MCS: 64 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 13. Chromosome analysis of the fetus is usually accomplished through the testing of which? a. Fetal serum b. Maternal urine c. Amniotic fluid d. Maternal serum ANS: C Amniocentesis is the most common method torrieve fetal cells for ochmrosome analysis. Viable fetal cells are sloughed off tion t he amniotic fluid, and when a sample is taken, they can be culturelydzaendd. ana It is fdiicfult to ob tainma pslae of the fetal blood. It is a high-risk situation for the fetus. Fetal cells are not present in the maternal urine or blood. DIF: Cognitive Level: Analyzing REF: MCS: 46 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. A couple asks the nurse about the optimal time for genetic counseling. They do not plan to have children for several years. When should the nurse recommend they begin genetic counseling? a. As soon as the woman suspects that she may be pregnant b. Whenever they are ready to start their family c. Now, if one of them has a family history of congenital heart disease d. Now, if they are members of a population at risk for certain diseases ANS: D Persons who seek genetic evaluation and counseling must first be aware if there is a genetic or potential problem in their families. Genetic testing should be done now if the couple is part of a population at risk. It is not feasible at this time to test for all genetic diseases. The optimal time for genetic counseling is before pregnancy occurs. During the pregnancy, genetic counseling may be indicated if a genetic disorder sispesucted. Congenital heart disease is not a esingl disorder. DIF: Cognitive Level: Applying REF: MCS: 62 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance -gene 15. A woman, age 43 years, is 6 weeks pregnant. It is important that she be informed of which? a. The need for a therapeutic abortion b. Increased risk for Down syndrome c. Increased risk for Turner syndrome d. The need for an immediate amniocentesis ANS: B Women who are older than age 35 years at the birth of a single child or s31a year t the birth of twins are advised to have prenatal diagnosis. The risk of having a child with Down syndrome increases with emrantal age. T here is no indication of a need for a therapeutic abortion at this stage. Turner syndrome is not associated with advanced maternal age.nAiomcentesis cannot be done at a gestational age of 6 weeks. DIF: Cognitive Level: Applying REF: MCS: 51 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 16. A couple has given birth to their first child, a boy with a recessive disorder. The genetic counselor tells them that the risk of recurrence is one in four. Which statement eiscta corr interpretation of this information? a. The risk factor remains the same for each pregnancy. b. The risk factor will change when they have a second child. c. Because the parents have one affected child, the next three children should be unaffected. d. Because the parents have one affected child, the next child is four times more likely to be affected. ANS: A Each pregnancyhheas t same risks for eacnteadffchild. Because an odds ratio reflects the risk, this does not change over time. The statement by the genetic counselor refers to a probability. This does not change over time. The statement Because the parents have one affected child, the next dchiil s four mti es more likely t ofbeectaefd doe s not lrecft au tosomal recessive inheritance. DIF: Cognitive Level: Analyzing REF: MCS: 57 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. A couple expecting their first child has a positive family history for several congenital defects and disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which should the nurse consider when counseling the couple? a. The couple should be encouraged to have recommended diagnostic testing. b. The couple needs counseling regarding advantages and disadvantages of pregnancy termination. c. Diagnostic testing is required by law in this situation. d. Diagnostic testing is of limited value if termination of pregnancy is not an option. ANS: A The benefits of prenatal diagnostic testing extend beyond decisions concerning abortion. If the child has congenital disorders, decisions can be made about fetal surgery if indicated. In addition, if the child is expected to require neonatal intensive care at birth, the mother is encouraged to deliver at a level III neonatal center. The couple is counseled about the advantages and disadvantages of prenatal diagnosis, not pregnancy termination, although the family cannot be forced to have prenatal testing. The information gives the parents time to grieve and plan for their child if congenital disorders are present. If the child is free of defects, then the parents are relieved of a major worry. DIF: Cognitive Level: Applying REF: MCS: 71 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 18. Parents ask the nurse if there was something that should have been done during the pregnancy to prevent their childs cleft lip. Which statement should the nurse give as a response? a. This is a type of deformation and can sometimes be prevented. b. Studies show that taking folic acid during pregnancy can prevent this defect. c. This is a genetic disorder and has a 25% chance of happening with each pregnancy. d. The malformation occurs at approximately 5 weeks of gestation; there is no known way to prevent this. ANS: D Cleft lip, an example of a malformation, occurs at approximately 5 weeks of gestation when the developing embryo naturally has two clefts in the area. There is no known way to prevent this defect. Deformations are often caused by extrinsic mechanical forces on normally developing tissue. Club foot is an example of a deformation often caused by uterine constraint. Cleft lip is not a genetic disorder; the reasons for this occurring are still unknown. Taking folic acid during pregnancy can help to prevent neural tube disorders but not cleft lip defects. DIF: Cognitive Level: Applying REF: MCS: 49 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is teaching parents of a child with cri du chat syndrome about this disorder. The nurse understands parents understand the teaching if they make which statement? a. This disorder is very common. b. This is an autosomal recessive disorder. c. The crying pattern is abnormal and catlike. d. The child will always have a moon-shaped face. ANS: C Typical of this disease is a crying pattern that is abnormal and catlike. Cri du chat, or cats cry, syndrome is a rare (one in 50,000 live births) chromosome deletion syndrome, not autosomal recessive, resulting from loss of the small arm of chromosome 5. In early infancy this syndrome manifests with a typical but nondistinctive facial appearance, often a moon-shaped face with wide-spaced eyes (hypertelorism). As the child grows, this feature is progressively diluted, and by age 2 years, the child is indistinguishable from age-matched control participants. DIF: Cognitive Level: Applying REF: pp. 54-55 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 20. The nurse is reviewing a clients prenatal history. Which prescribed medication does the nurse understand is not considered a teratogen and prescribed during pregnancy? a. Phenytoin (Dilantin) b. Warfarin (Coumadin) c. Isotretinoin (Accutane) d. Heparin sodium (Heparin) ANS: D Teratogens, agents that cause birth defects when present in the prenatal environment, account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin], isotretinoin [Accutane]). Heparin is the anticoagulant used during pregnancy and is not a teratogen. It does not cross the placenta. DIF: Cognitive Level: Analyzing REF: MCS: 68 TOP: Nursing Process: Evaluation MSC: Integrated Process: Physiological Integrity 21. The nurse is teaching student nurses about newborn screening. Which statement made by the student indicates understanding of the teaching? a. The newborn screening is not mandatory but voluntary. b. It is acceptable to layer the blood on the Guthrie paper. c. The initial specimen should be collected as close to discharge as possible. d. It is best to collect the specimen before the newborn takes the first feeding. ANS: C Because of early discharge of newborns, recommendations for screening include collecting the initial specimen as close as possible to discharge. Newborn screening tests are mandatory in all 50 U.S. states. When collecting the specimen, avoid layering the blood specimen on the special Guthrie paper. Layering is placing one drop of blood on top of the other or overlapping the specimen. Best results are obtained by collecting the cspime en w ith eatpteipf rom the lhesteick and spreading the blood uniformly over the blot paper. The screening test is most reliable if the blood sample is taken after the infant has ingested a source of protein. DIF: Cognitive Level: Applying REF: MCS: 71 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. A hospitalized school-age child with phenylketonuria (PKU) is choosing foods from the hospitals menu. Which food choice should the nurse discourage the child from choosing? a. Banana b. Milkshake c. Fruit juice d. Corn on the cob ANS: B Foods with low phenylalanine levels (e.g., some vegetables [except legumes]; fruits; juices; and some cereals, breads, and starches) must be measured to provide the prescribed amount of phenylalanine. Most high-protein foods, such as meat and dairy products, are either eliminated or restricted to small amounts. DIF: Cognitive Level: Applying REF: pp. 71-72 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 23. The nurse understands that which occurring soon after birth can indicate cystic fibrosis? a. Murmur b. Hypoglycemia c. Meconium ileus d. Muscle weakness ANS: C A symptom of cystic fibrosis is a meconium ileus soon after birth. A murmur can be a sign of a congenital heart disease. Hypoglycemia can be a sign of Beckwith-Wiedemann syndrome. Muscle weakness can be a sign of myotonic dystrophy. DIF: Cognitive Level: Understanding REF: MCS: 59 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion andtMenannce 24. A newborn has been diagnosed with congenital adrenal hyperplasia. Which assessment finding should the nurse expect? a. Ambiguous genitalia b. Prenatal growth retardation c. An abnormally large tongue d. Legs and arms significantly shorter than torso ANS: A A newborn diagnosed with congenital adrenal hyperplasia can have ambiguous genitalia or virilization of female external genitalia caused by elevated androgen levels. Prenatal growth retardation is present with Bloom syndrome. An abnormally large tongue is seen with Beckwith- Wiedemann syndrome. Legs and arms significantly shorter than torso are seen with achondroplasia. DIF: Cognitive Level: Analyzing REF: MCS: 59 TOP: Nursing Process: Assessment :MISC ntegrated Process: Physiological Itengrity 25. Parents of a child with hemophilia A ask the nurse, What is the deficiency with this disorder? Which correct response should the nurse make? a. Hemophilia A has a deficiency in red blood cells. b. Hemophilia A has a deficiency in platelets. c. Hemophilia A has a deficiency in factor IX. d. Hemophilia A has a deficiency in factor VIII. ANS: D Hemophilia A is deficient in factor VIII. Glucose-6-phosphate dehydrogenase (G6PD) deficiency shows low red blood cells (hemolytic anemia). Immunosuppression may be the cause of a deficient number of platelets. Hemophilia B is deficient in factor IX. DIF: Cognitive Level: Applying REF: MCS: 60 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 26. A child with Prader-Willi syndrome has been hospitalized. Which assessment findings does the nurse expect with this syndrome? a. Nonverbal b. Insatiable hunger c. Abnormal, puppetlike gait d. Paroxysms of inappropriate laughter ANS: B Prader-Willi syndrome is characterized by insatiable hunger that can lead to morbid obesity in childhood. Abnormal, puppetlike gait, paroxysms of inappropriate laughter, and nonverbal are characteristics seen in Angelman syndrome. DIF: Cognitive Level: Analyzing REF: MCS: 66 TOP: NursoicnegssP:rAssessment :MISC ntegrated Process: Physiological Itengrity 27. Which ethnic group is at risk for Tay-Sachs disease? a. Black African b. Mediterranean c. Ashkenazi Jewish d. Southern and Southeast Asian ANS: C The Ashkenazi Jewish ethnic group is at higher risk for Tay-Sachs disease. The black African, Mediterranean, and Southern and Southeast Asian ethnicities are at higher risk for sickle cell anemia disease. DIF: Cognitive Level: Understanding REF: MCS: 78 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. A child has been found to have a deficiency in 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Which condition is this child at risk for? a. Increased uric acid b. Hypercholesterolemia c. Increased phenylketones d. Altered oxygen transport ANS: B HMG-CoA leads to a disruption of metabolic feedback mechanism and accumulation of end product (cholesterol) with the resulting condition of hypercholesterolemia. DIF: Cognitive Level: Analyzing REF: MCS: 48 TOP: NursoicnegssP:rAssessment :MISC ntegrated Process: Physiological Itengrity 29. Phenylketonuria is a genetic disease that results in the bodys inability to correctly metabolize which? a. Glucose b. Thyroxine c. Phenylalanine d. Phenylketones ANS: C Phenylketonuria is an inborn error of metabolism caused by a deficiency eonr caebs of the enzyme needed to metabolize the essential amino acid phenylalanine. Individuals with this disorder can metabolize glucose. Thyroxine is one of the principal hormones secreted by the thyroid gland. Phenylketones are metabolites of phenylalanine excreted in the urine. DIF: Cognitive Level: Understanding REF: MCS: 61 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. Early diagnosis of congenital hypothyroidism (CH) and phenylketonuria (PKU) is essential to prevent which? a. Obesity b. Diabetes c. Cognitive impairment d. Respiratory distress ANS: C Untreated, both PKU and CH cause cognitive impairment. With newborn screening and early intervention, cognitive impairment from these two disorders can be prevented. Obesity, diabetes, and respiratory distress do not result from both CH and PKU. DIF: Cognitive Level: Understanding REF: MCS: 61 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 31. A breastfed infant has just been adgi nosed w ith galactosemia. The therapeutic management of this includes which? a. Stop breastfeeding the infant. b. Add amino acids to breast milk. c. Substitute a lactose-containing formula for breast milk. d. Give the appropriate enzyme along with breast milk. ANS: A The infant with galactosemia is fed a diet free of all milk and lactose-containing foods. This includes breast milk. Soy-protein formula is the formula of choice. Other strategies are being identified. DIF: Cognitive Level: Understanding REF: pp. 73-74 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. Which can be directly attributed to a single-gene disorder? (Select all that apply.) a. Cleft lip b. Cystic fibrosis c. Turner syndrome d. Klinefelter syndrome e. Neurofibromatosis ANS: B, E Cystic fibrosis is a single-gene disorder inherited as an autosomal recessive trait, and neurofibromatosis is a single-gene disorder inherited as an autosomal dominant trait. Cleft lip is classified as a multifactorial disorder in which a genetic susceptibility and appropriate environment appear to play important roles. Turner and Klinefelter syndromes are disorders of sex chromosome number. DIF: Cognitive Level: Analyzing REF: MCS: 49 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. The nurse is reviewing the characteristics of autosomal dominant inheritance. Which are true about these characteristics? (Select all that apply.) a. A carrier state exists. b. The phenotype appears in consecutive generations. c. Males and females are equally likely to be affected. d. Parents who have affected children are usually asymptomatic. e. Children of an affected parent have a 50% chance of being affected. ANS: B, C, E Characteristics of autosomal dominant inheritance include the phenotype appears in consecutive generations, males and females are equally affected, and children of eancteadff pa rent have a 50% chance of being affected. A carriertsetand parents who have affected children are usually asymptomatic are characteristic of autosomal recessive inheritance. DIF: Cognitive Level: Analyzing REF: MCS: 55 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. The nurse is reviewing the characteristics of autosomal recessive inheritance. Which are true about these characteristics? (Select all that apply.) a. Most affected persons are males. b. Males and females are equally affected. c. All daughters of an affected male are carriers. d. Carrier parents have a 25% chance of producing an affected child. e. Carrier parents have a 50% chance of producing a carrier child in each pregnancy. ANS: B, D, E Characteristics of autosomal recessive inheritance include males and females are equally affected, carrier parents have a 25% chance of ipnrgoduc anfaefcted child, and car rier parents have a 50% chance of producing a carrier child in each pregnancy. Most affected persons who are males and all daughters of aneacftfed m ale are carriers are characteristics of X-linked recessive inheritance. DIF: Cognitive Level: Analyzing REF: MCS: 57 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Which are signs and symptoms the nurse should assess in the newborn that can indicate an inborn error of metabolism? (Select all that apply.) a. Jaundice b. Strabismus c. Poor feeding d. Acrocyanosis e. Metabolic acidosis ANS: A, C, E Signs of inborn errors of metabolism include jaundice, poor feeding, and metabolic acidosis. Strabismus and acrocyanosis are normal findings in the newborn. Chapter 4.Communication, Physical, and Developmental Assessment of the Child and Family MULTIPLE CHOICE 1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? a. Introduce him- or herself. b. Make the family comfortable. c. Give assurance of privacy. d. Explain the purpose of the interview. ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in anoennmviernt as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality. DIF: Cognitive Level: Applying REF: MCS: 91 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 2. Which is considered a block to effective communication? a. Using silence b. Using clichs c. Directing the focus d. Defining the problem ANS: B Using stereotyped comments or clichs can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for nressepsoto questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintaintaiorneslhaip w ith the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention. DIF: Cognitive Level: Applying REF: MCS: 94 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 3. Which is the single most important factor to consider when communicating with children? a. Presence of the childs parent b. Childs physical condition c. Childs developmental level d. Childs nonverbal behaviors ANS: C The nurse must be aware of tchheilds developmental s tage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on tchheilds developmental level and physical condition. Although the childs physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents. DIF: Cognitive Level: Understanding REF: MCS: 147 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 4. Because children younger than 5 years are egocentric, ethnurse should do which when communicating with them? a. Focus communication on the child. b. Use easy analogies when possible. c. Explain experiences of others to the child. d. Assure the child that communication is private. ANS: A Because childrensoafgtehi are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not bfeecetifve because the child is not capable of understanding. DIF: Cognitive Level: Understanding REF: MCS: 96 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 5. The nurses approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? a. The child may think the equipment is alive. b. Explaining the equipment will only increase the childs fear. c. One brief explanation will be enough to reduce the childs fear. d. The child is too young to understand what the equipment does. ANS: A Young rcihbiuldt ren att e human characteristics to inanimate objects.eTyhof ten fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the childs fear. Preschoolers need raetepde explanations as reassurance. DIF: Cognitive Level: Analyzing REF: MCS: 112 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. When the nurse interviews an adolescent, which is especially important? a. Focus the discussion on the peer group. b. Allow an opportunity to express feelings. c. Use the same type of language as the adolescent. d. Emphasize that confidentiality will always be maintained. ANS: B Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent. DIF: Cognitive Level: Understanding REF: MCS: 96 | MCS: 97 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate? a. Initiate a game of peek-a-boo. b. Ask the infants father to place the infant on the examination table. c. Talk softly to the infant while taking him from his father. d. Undress the infant while he is still sitting on his fathers lap. ANS: A Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination. DIF: Cognitive Level: Applying REF: MCS: 97 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 8. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which? a. Ask her why she wants to know. b. Determine why she is so anxious. c. Explain in simple terms how it works. d. Tell her she will see how it works as it is used. ANS: C School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur. DIF: Cognitive Level: Applying REF: MCS: 96 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful? a. Recommend that the child keep a diary. b. Provide supplies for the child to draw a picture. c. Suggest that the parent read fairy tales to the child. d. Ask the parent if the child is always uncommunicative. ANS: B Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childrens inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative. DIF: Cognitive Level: Applying REF: MCS: 99 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 10. Which data should be included in a health history? a. Review of systems b. Physical assessment c. Growth measurements d. Record of vital signs ANS: A A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination. DIF: Cognitive Level: Remembering REF: MCS: 100 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 11. The nurse is taking a health history of an adolescent. Which best describes how ethchief complaint should be determined? a. Request a detailed listing of symptoms. b. Ask the adolescent, Why did you come here today? c. Interview the parent away from the adolescent to determine the chief complaint. d. Use what the adolescent says to determine, in correct medical terminology, what the problem is. ANS: B The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the icehf complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent tiesnsteieokning at at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. DIF: Cognitive Level: Applying REF: MCS: 99 TOP: Nursing Process: Assessment :MCSlCient Needs: Health Promotion and Maintenance 12. The nurse is interviewing the mother of an infant. The mother reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading? a. History b. Present illness c. Chief complaint d. Review of systems ANS: A The thoirsy refers to information that relates to previous aspects of the iclhds lhteha, not to the current problem. The difficult delivery and prematurity are pimortant parts of the infants history. The history of the present linl e ss is a narrative of the chief complaint ofrm i ts earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the childs vitisto the clinic,ioceff, or hospital.hIot usld not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction. DIF: Cognitive Level: Understanding REF: MCS: 100 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 13. Where in the health history does a record of immunizations belong? a. History b. Present illness c. Review of systems d. Physical assessment ANS: A The history contains information relating to all previous aspects of the childs health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status. DIF: Cognitive Level: Understanding REF: MCS: 100 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 14. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? a. Ask her, Are you sexually active? b. Ask her, Are you having sex with anyone? c. Ask her, Are you having sex with a boyfriend? d. Ask both the girl and her parent if she is sexually active. ANS: B Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone. DIF: Cognitive Level: Applying REF: MCS: 102 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 15. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which? a. Lacking in protein b. Indicating they live in poverty c. Providing sufficient amino acids d. Needing enrichment with meat and milk ANS: C A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth. DIF: Cognitive Level: Applying REF: MCS: 106 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 16. Which parameter correlates best withemntesaosuf rem total muscle mass? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference ANS: D Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the bodys fat content. DIF: Cognitive Level: Understanding REF: MCS: 122 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 17. The nurse is preparing tofpoermr a physical a esnstessm on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which? a. Appropriate because of childs age b. Appropriate, but the mother may be uncomfortable c. Inappropriate because of childs age d. Inappropriate because child is same sex as mother ANS: A It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, andepnatr s are responsible for thheaclar e decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination. DIF: Cognitive Level: Applying REF: MCS: 112 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 18. With the tNioanal Center for Health S tatistics criteria, whichsbsoidnydema percentiles should indicate the patient is at risk for being overweight? a. 10th percentile b. 75th percentile x (BMI)for-age c. 85th percentile d. 95th percentile ANS: C Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits. DIF: Cognitive Level: Understanding REF: MCS: 117 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 19. Rectal temperatures are indicated in which situation? a. In the newborn period b. Whenever accuracy is essential c. Rectal temperatures are never indicated d. When rapid temperature changes are occurring ANS: B Rectal temperatures are recommended whenidneitfive measurements are necessary i naintfs older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mo uc sa. Rectal temperature is an intrusive procedure that should be avoided whenever possible. DIF: Cognitive Level: Understanding REF: MCS: 118 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year b. 2 years c. 3 years d. 6 years ANS: B Satisfactory erasdial puls can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable. DIF: Cognitive Level: Understanding REF: MCS: 140 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 21. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and sontoeoi small. The best nursing action is which? a. Use the small cuff. b. Use the large cuff. c. Use either cuff using the palpation method. d. Wait to take the blood pressure until a proper cuff can be located. ANS: B If blood pressure measurement nisdiicated and the appropriate size cuff is not laavbalie, the next larger size is used. Tnhuerse recognizes that thi s may be a falsely low blood pressure. Using the small cuff will give an incorrectly high dreinag. The palpation method will pnrootvime the inaccuracy inherent in the cuff. DIF: Cognitive Level: Applying REF: MCS: 110 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 22. Where is the best place to oerbvse for tphreesence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles ANS: C Petechiae, small distinct pinpoint hemorrhages, fairceudltifto see in dark- skinned individuals unless they are in the mouth or conjunctiva. DIF: Cognitive Level: Understanding REF: MCS: 124 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Health Promotion and Maintenance 23. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action? a. Recheck head control at next visit. b. Teach the parents appropriate exercises. c. Schedule the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open. ANS: C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated. DIF: Cognitive Level: Applying REF: pp. 125-126 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 24. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action? a. Ask the parent when the neck was injured. b. Refer for immediate medical evaluation. c. Continue assessment to determine the cause of the neck pain. d. Record head lag on the assessment record and continue the assessment of the child. ANS: B Hyperextension of the childs head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag. DIF: Cognitive Level: Analyzing REF: MCS: 125 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 25. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which? a. A normal finding b. A sign of a possible visual defect and a need for vision screening c. An abnormal finding requiring referral to an ophthalmologist d. A sign of small hemorrhages, which usually resolve spontaneously ANS: A A biarniltl, uniform re d reflex pisoartnanimt normal finding. It rules out many serious edcetfs of the cornea, aqueous chamber, lens, and vitreous chamber. DIF: Cognitive Level: Analyzing REF: MCS: 127 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 26. Which explains the importance of detecting strabismus in young children? a. Color vision deficit may result. b. Amblyopia, a type of blindness, may result. c. Epicanthal folds may develop in the affected eye. d. Corneal light reflexes may fall symmetrically within each pupil. ANS: B By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes lazy, and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the ncoear l light reflex will not be symmetric for each eye. DIF: Cognitive Level: Understanding REF: MCS: 127 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 27. Which is the most frequently used test for measuring visual acuity? a. Snellen letter chart b. Ishihara vision test c. Allen picture card test d. Denver eye screening test ANS: A The Snellen letter chart, which consists of nlies of l etters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for lcdhrien ag es 2 years and older who are unable to use the Snellen letter chart. DIF: Cognitive Level: Understanding REF: MCS: 129 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. The nurse is testing an infants visual acuity. By which age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months d. 6 months ANS: C Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed. DIF: Cognitive Level: Applying REF: MCS: 129 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 29. During an otoscopic examination on an infant, in which direction is the pinna pulled? a. Up and back b. Up and forward c. Down and back d. Down and forward ANS: C In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 oclock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 oclock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal. DIF: Cognitive Level: Understanding REF: MCS: 131 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 30. What is an appropriate screening test for hearing that the sneurc child? a. Rinne test b. Weber test c. Pure tone audiometry d. Eliciting the startle reflex ANS: C na administer to ar5-ye -old Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the childs ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and sWtseber te reflex may be useful in infants. measure bone conduction of sound. Eliciting the startle DIF: Cognitive Level: Understanding REF: MCS: 132 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 31. What is the appropriate placement of a tongue blade for assessment of the mouth and throat? a. On the lower jaw b. Side of the tongue c. Against the soft palate d. Center back area of the tongue ANS: B The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. On the lower jaw and against the soft palate are not appropriate places for the tongue blade. Placement in the center back area of the tongue elicits the gag reflex. DIF: Cognitive Level: Applying REF: MCS: 134 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 32. When assessing a preschoolers chest, what should the nurse expect? a. Respiratory movements to be chiefly thoracic b. Anteroposterior diameter to be equal to the transverse diameter c. Retraction of the muscles between the ribs on respiratory movement d. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing ANS: D Movement of the chest wall should be symmetric bilaterally and coordinated with breathing. In children younger than 6 or 7 years, respiratory movement is principally abdominal or diaphragmatic. Tahneteroposterior admi eter is equal to the transverse diameter during infancy. As the child grows, the chest increases in the transverse direction, so that the anteroposterior diameter is less than the lateral diameter. Retractions of the muscles between the ribs on respiratory movement are indicative of respiratory distress. DIF: Cognitive Level: Applying REF: MCS: 135 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 33. When auscultating an infants lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as? a. Suggestive of chronic pulmonary disease b. Suggestive of impending respiratory failure c. An abnormal finding warranting investigation d. A normal finding in infants younger than 1 year of age ANS: C Absent or diminished breath sounds are always an abnormal finding. Fluid, air, or solid masses in the pleural space all interfere with the conduction of breath sounds. Further data are necessary for diagnosis of chronic pulmonary disease or impending respiratory failure. Diminished breath sounds in certain segments of the lungs can alert the nurse to pulmonary areas that may benefit from chest physiotherapy. Further evaluation is needed in all age groups. DIF: Cognitive Level: Analyzing REF: MCS: 137 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 34. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular b. Bronchial c. Adventitious d. Bronchovesicular ANS: A This is the definition of vesicular breath sounds.yTahre e heard over the entire surface of the lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions, where the trachea and bronchi bifurcate. DIF: Cognitive Level: Understanding REF: MCS: 137 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 35. The nurse is assessing a childs capillary refill time. This can be accomplished by doing what? a. Inspect the chest. b. Auscultate the heart. c. Palpate the apical pulse. d. Palpate the nail bed with pressure to produce a slight blanching. ANS: D Capillary refill time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary refill time. DIF: Cognitive Level: Applying REF: MCS: 139 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 36. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the kb-ac and-forth flow of blood? a. S1 and S2 b. S3 and S4 c. Murmur d. Physiologic splitting ANS: C Murmurs are the sounds thaa re produced inethhe art chambers or omraj earites from t he back- and-forth flow of blood. S1 and S2 are normal heart sounds. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves. S3 is a normal heart sound sometimes heard in children. S4airserly he ard as a normal heart sound. If it is heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding. DIF: Cognitive Level: Understanding REF: MCS: 140 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 37. Examination of the abdomen is performed correctly by the nurse in which order? a. Inspection, palpation, percussion, and auscultation b. Inspection, percussion, auscultation, and palpation c. Palpation, percussion, auscultation, and inspection d. Inspection, auscultation, percussion, and palpation ANS: D The correct order of abdominal examination is inspection, auscultation, percussion, and palpation. Palpation is always performed last because it may distort the normal abdominal sounds. Auscultation is performed before percussion. The act of percussion can influence the findings on auscultation. DIF: Cognitive Level: Understanding REF: pp. 141-142 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 38. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? a. Palpate another area simultaneously. b. Ask the child not to laugh or move if it tickles. c. Begin with deeper palpation and gradually progress to superficial palpation. d. Have the child help with palpation by placing his or her hand over the palpating hand. ANS: D Having the child help with palpation by placing his or her hand over the palpating hand will help minimize the feeling of tickling and enlist the childs cooperation. Palpating another area simultaneously will create the sensation of tickling in the other area also. Asking the child not to laugh or move will bring attention to the tickling and make it more difficult for the child. Superficial palpation is done before deep palpation. DIF: Cognitive Level: Applying REF: MCS: 142 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 39. During examination of a toddlers extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which? a. Abnormal and requires further investigation b. Abnormal unless it occurs in conjunction with knock-knee c. Normal if the condition is unilateral or asymmetric d. Normal because the lower back and leg muscles are not yet well developed ANS: D Lateral bowing of the tibia (bowlegged) is an expected finding in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are lwoepleldd.eve Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African American children. DIF: Cognitive Level: Understanding REF: MCS: 145 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 40. The nurse is caring for a nonEnglish-speaking child and family. Which should the nurse consider when using an interpreter? a. Pose several questions at a time. b. Use medical jargon when possible. c. Communicate directly with family members when asking questions. d. Carry on some communication in English with the interpreter about the familys needs. ANS: C When using an interpreter, the nurse should communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions. Questions should be posed one at a time to elicit only one answer at a time. Medical jargon should be avoided whenever possible. The nurse should avoid discussing the familys needs with the interpreter in English because some family members may understand some English. DIF: Cognitive Level: Applying REF: MCS: 94 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 41. Which action should the nurse implement when taking an axillary temperature? a. Take the temperature through one layer of clothing. b. Add a degree to the result when recording the temperature. c. Place the tip of the thermometer under the arm in the center of the axilla. d. Hold the childs arm away from the body while taking the temperature. ANS: C The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The childs arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method. DIF: Cognitive Level: Applying REF: MCS: 119 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 42. The nurse is aware that skin turgor best estimates what? a. Perfusion b. Adequate hydration c. Amount of body fat d. Amount of anemia ANS: B Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia. DIF: Cognitive Level: Understanding REF: MCS: 125 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 43. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences? a. The parent feels inferior to the nurse. b. The parent is showing respect for the nurse. c. The parent is embarrassed to seek health care. d. The parent feels responsible for her childs illness. ANS: B In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurses eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse. DIF: Cognitive Level: Analyzing REF: MCS: 93 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.) a. Ashen gray areas b. A well-defined light reflex c. A small, round, concave spot near the center of the drum d. The tympanic membrane is a nontransparent grayish color e. A whitish line extending from the umbo upward to the margin of the membrane ANS: B, C, E Normal findings include the light reflex and bony landmarks. The light reflex is a fairly well- defined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation. DIF: Cognitive Level: Understanding REF: MCS: 132 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) a. Wheezes b. Crackles c. Vesicular d. Bronchial e. Bronchovesicular ANS: C, D, E Normal breath sounds are classified as vesicular, bronchovesicular, or obrnchial. W heezes or crackles are abnormal or adventitious sounds. DIF: Cognitive Level: Applying REF: MCS: 137 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) a. Lightly brush the palate with a cotton swab. b. Perform the examination in front of a mirror. c. Let the child examine someone elses mouth first. d. Have the child breathe deeply and hold his or her breath. e. Use a tongue blade to help the child open his or her mouth. ANS: A, B, C, D To encourage a child to open the mouth for examination, the nurse can lightly brush the palate with a cotton swab, perform the examination in front of a mirror, let the child examine someone elses mouth first, and have the child breathe deeply and hold his or her breath. A tongue blade may elicit the gag reflex and should not be used. DIF: Cognitive Level: Applying REF: MCS: 134 TOP: NursoicnegssP:rAssessment lMieSnCt : C Needs: Physiological Integrity 4. Which are effective auscultation techniques? (Select all that apply.) a. Ask the child to breathe shallowly. b. Apply light pressure on the chest piece. c. Use a symmetric and orderly approach. d. Place the stethoscope over one layer of clothing. e. Warm the stethoscope before placing it on the skin. ANS: C, E Effective auscultation techniques include using a symmetric approach and warming the stethoscope before placing it on the skin. Breath sounds are best heard if the child inspires deeply, not shallowly. Firm, not light, pressure should be used on the chest piece. The stethoscope should be placed on the skin, not over clothing. DIF: Cognitive Level: Understanding REF: MCS: 137 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Physiological Integrity 5. The nurse is assessing thesoarund s on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.) a. S4 heart sound b. S3 heart sound c. Grade II murmur d. S1 louder at the apex of the heart e. S2 louder than S1 in the aortic area ANS: A, C, E S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area. DIF: Cognitive Level: Applying REF: pp. 139-140 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Physiological Integrity 6. The nurse understands that blocks to therapeutic communication include what? (Select all that apply.) a. Socializing b. Use of silence c. Using clichs d. Defending a situation e. Using open-ended questions ANS: A, C, D Blocks to communication include socializing, using clichs, and defending a situation. Use of silence and using open-ended questions are therapeutic communication techniques. Chapter 5.Pain in Children: Significance, Assessment, and Management Strategies MULTIPLE CHOICE 1. Which is the most consistent and commonly used data for assessment of pain in infants? a. Self-report b. Behavioral c. Physiologic d. Parental report ANS: B Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not oabdleistinguish between phy sical responses to pain and other forms of streresns.taPlareport without a s tructured tool maycncoutrately reflec t the degree of discomfort. DIF: Cognitive Level: Understanding REF: MCS: 152 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group? a. No hurt. b. Red pain. c. Zero hurt. d. Least pain. ANS: A No hurt is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. Least pain is less concrete than no hurt. DIF: Cognitive Level: Applying REF: MCS: 154 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 3. What is an important consideration when using the FACES pain rating scale with children? a. Children color the face with the color they choose to best describe their pain. b. The scale can be used with most children as young as 3 years. c. The scale is not appropriate for use with adolescents. d. The FACES scale is useful in pain assessment but is not as accurate as physiologic responses. ANS: B The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The childs estimate of the pain should be used. The physiologic measures may not reflect more long-term pain. DIF: Cognitive Level: Applying REF: MCS: 154 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 4. What describes nonpharmacologic techniques for pain management? a. They may reduce pain perception. b. They usually take too long to implement. c. They make pharmacologic strategies unnecessary. d. They trick children into believing they do not have pain. ANS: A Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the childs pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the childs experience with mild pain, but the child will still know the discomfort was present. DIF: Cognitive Level: Analyzing REF: pp. 163-164 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 5. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain? a. Tactile stimulation b. Commercial warm packs c. Doing procedure during infant sleep d. Oral sucrose and nonnutritive sucking ANS: D Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles. DIF: Cognitive Level: Analyzing REF: MCS: 165 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 6. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. dWyhoaut rshoul explanation to the parents include? a. The child will continue to sleep and be pain free. b. Parents cannot administer additional medication with the button. c. The pump can deliver baseline and bolus dosages. d. There is a high risk of overdose, so monitoring is done every 15 minutes. ANS: C The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year- old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient. DIF: Cognitive Level: Applying REF: MCS: 176 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 7In. tWeghricyh drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine sulfate (Codeine) b. Morphine (Roxanol) c. Methadone (Dolophine) d. Meperidine (Demerol) ANS: B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief. DIF: Cognitive Level: Analyzing REF: MCS: 176 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 8. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which? a. Give only an opioid analgesic at this time. b. Increase dosage of analgesic until the child is adequately sedated. c. Plan a preventive schedule of pain medication around the clock. d. Give the child a clock and explain when she or he can have pain medications. ANS: C For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for ethpresent, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the childs attention on how long he or she will need to wait for pain relief. DIF: Cognitive Level: Implementation REF: MCS: 176 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 9. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurses response should be based on which characteristic about preterm infants pain? a. They may react to painful stimuli but are unable to remember the pain experience. b. They perceive and react to pain in much the same manner as children and adults. c. They do not have the cortical and subcortical centers that are needed for pain perception. d. They lack neurochemical systems associated with pain transmission and modulation. ANS: B Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as childrtesn. Panredteardmuli nfants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, andohnoarlmand metabolic changes.qAudate are necessary to decrease the stress response. DIF: Cognitive Level: Analyzing REF: MCS: 153 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity e analgesia and anesthesia 10. A preterm infant has just been admitted to the neonatal intensive care unit. The infants parents ask the nurse about tahneessia and analgesia when painful procedures are necessary. What should the nurses explanation be? a. Nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli. b. The risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief. c. Neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences. d. Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. ANS: D Pain pathways and cnheuemroical sys emst associated w th ip ain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, andohnoarlmand metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates. DIF: Cognitive Level: Analyzing REF: MCS: 185 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 11. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which? a. Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure. b. Use a combination of fentanyl and midazolam for conscious sedation. c. Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure. d. Apply a transdermal fentanyl (Duragesic) patch immediately before the procedure. ANS: B A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is aneecftfive topical analgesic agent w hen applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For rthoicsepdure, sys emitc analgesia is required. T ransdermal fentanyl patches are useful for continuous pain control, not rapid pain control. DIF: Cognitive Level: Analyzing REF: MCS: 185 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. What is a significant common side effect that occurs with opioid administration? a. Euphoria b. Diuresis c. Constipation d. Allergic reactions ANS: C Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus. DIF: Cognitive Level: Remembering REF: MCS: 171 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 13. The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first? a. Administer naloxone (Narcan). b. Discontinue the IV infusion. c. Discontinue morphine until the child is fully awake. d. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply. ANS: A The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the iclhd. If thepirarteosry rate esse is depr d and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive. DIF: Cognitive Level: Applying REF: MCS: 180 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 14. The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching? a. With minimal sedation, the patients respiratory efforts are affected, and cognitive function is not impaired. b. With general anesthesia, the patients airway cannot be maintained, but cardiovascular function is maintained. c. During deep sedation, the patient can be easily aroused by loud verbal commands and tactile stimulation. d. During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation. ANS: D When discussing levels of sedation, the participants should understand that during moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by uplainf stimuli; the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia, the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired. DIF: Cognitive Level: Analyzing REF: MCS: 184 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 15. The nurse is planning to administer a nonopioid for pain relief to a child. Which timing should the nurse plan so the nonopioid takes effect? a. 15 minutes until maximum effect b. 30 minutes until maximum effect c. 1 hour until maximum effect d. 1 1/2 hours until maximum effect ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) can provide safe and effective pain lrieef w hen dosed at appropriate levels with adequate frequency. Most NSAIDs take about 1 hour for effect, so timing is crucial. DIF: Cognitive Level: Applying REF: MCS: 171 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 16. The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route? a. Less expensive than oral medications b. Produces a first-pass effect through the liver c. Does not need to be administered frequently d. Provides most rapid onset of effect, usually in about 5 minutes ANS: D The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the frist -pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control. DIF: Cognitive Level: Applying REF: MCS: 176 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 17. The nurse is teaching tphaerents of a child with recurrent headaches methods to modify behavior patterns that increase the risk of chheea.dWa understanding the teaching? hich st atement ebypathrents indicates a. We will allow the child to miss school if a headache occurs. b. We will respond matter-of-factly to requests for special attention. c. We will be sure to give much attention to our child when a headache occurs. d. We will be sure our child doesnt have to perform at a band concert if a headache occurs. ANS: B To modify behavior patterns that increase the risk of headache or reinforce headache activity, the nurse instructs the parents to avoid giving excessive attention to their childs headache and to respond matter-of-factly to pain behavior and requests for special attention. Parents learn to assess whether the child is avoiding school or social performance demands because of headache. DIF: Cognitive Level: Applying REF: MCS: 186 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological Integrity 18. Which is a complication that can occur after abdominal surgery if pain is not managed? a. Atelectasis b. Hypoglycemia c. Decrease in heart rate d. Increase in cardiac output ANS: A Pain associated with surgery in the abdominal region (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications such as pneumonia and atelectasis is high. Severe postoperative pain also results in sympathetic overactivity, which leads to increases in heart irpathee,rpael r resistance, blood pressure, iaancdocuatrpdut. H poyglycemia, de creases in heart rate, and increases in cardiac output are not complications of poor pain management. DIF: Cognitive Level: Analyzing REF: MCS: 185 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 19. A burn patient is experiencing anxiety over dressing changes. Which prescription should the nurse expect to be ordered to control anxiety? a. Lorazepam (Ativan) b. Oxycodone (OxyContin) c. Fentanyl (Sublimaze) d. Morphine Sulfate (Morphine) ANS: A A benzodiazepine such as lorazepam is prescribed as an antianxiety agent. Oxycodone, fentanyl, and morphine sulfate are opioid analgesics. DIF: Cognitive Level: Applying REF: MCS: 186 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 20. A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety? a. Lorazepam (Ativan) b. Gabapentin (Neurontin) c. Hydromorphone (Dilaudid) d. Morphine sulfate (MS Contin) ANS: B Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics. DIF: Cognitive Level: Applying REF: MCS: 189 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity MULTIPLE RESPONSE 1. Which are components of the FLACC scale? (Select all that apply.) a. Color b. Capillary refill time c. Leg position d. Facial expression e. Activity ANS: C, D, E Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC scale. DIF: Cognitive Level: Understanding REF: MCS: 154 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.) a. Color b. Moro reflex c. Oxygen saturation d. Posture of arms and legs e. Sleeplessness f. Facial expression ANS: C, E, F Need for rinecased oxyg en, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale. DIF: Cognitive Level: Applying REF: MCS: 159 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 3. Which coanalgesics should the nurse expect to be prescribed for pruritus? (Select all that apply.) a. Naloxone (Narcan) b. Inapsine (Droperidol) c. Hydroxyzine (Atarax) d. Promethazine (Phenergan) e. Diphenhydramine (Benadryl) ANS: A, C, E The coanalgesics prescribed for pruritus include naloxone, hydroxyzine, and diphenhydramine. Inapsine and promethazine are administered as antiemetics. DIF: Cognitive Level: Applying REF: MCS: 174 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 4. A child receiving chemotherapy is experiencing mucositis. Which prescriptions should the nurse plan to administer for initial treatment? (Select all that apply.) a. Scope mouth rinse b. Listerine antiseptic mouth rinse c. Carafate suspension (Sucralfate) d. Nystatin oral suspension (Nystatin) e. Lidocaine viscous (Lidocaine hydrochloride solution) ANS: C, D, E Initial treatment of stomatitis includes single agents (sucralfate suspension, nystatin, and viscous lidocaine). Scope and Listerine are plaque and gingivitis control mouth rinses that would have a drying effect and are not used with mucositis. DIF: Cognitive Level: Applying REF: MCS: 188 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity COMPLETION 1. A health care provider prescribes promethazine (Phenergan), 9 mg IV every 6 to 8 hours as needed for pruritus. The medication label states: Promethazine 25 mg/1 mL. The nurse prepares to administer one .dHosoew many milliliters will tehpernepuarsre to a dminister one dose? Fill in the blank. Record your answer using two decimal places. ANS: 0.36 Follow the formula for dosage calculation. Desired Volume = mL per dose Available 9 mg 1 mL = 0.36 mL 25 mg DIF: Cognitive Level: Applying REF: MCS: 174 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. A health care provider prescribes diphenhydramine (Benadryl), 1 mg/kg PO every 4 to 6 hours as needed for pruritus. The child weighs 10 kg. The medication label states: Diphenhydramine 12.5 mg/5 mL. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number. ANS: 4 Follow the formula for dosage calculation. Multiply 1 mg 10 kg to get the dose = 10 mg Desired Volume = mL per dose Available 10 mg 5 mL = 4 mL 12.5 mg DIF: Cognitive Level: Applying REF: MCS: 174 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. A health care provider prescribes hydroxyzine (Atarax), 0.6 mg/kg PO every 4 to 6 hours as needed for pruritus. The medication label states: Hydroxyzine 10 mg/5 mL. The child weighs 20 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number. ANS: 6 Follow the formula for dosage calculation. Multiply 0.6 mg 20 kg to get the dose = 12 mg Desired Volume = mL per dose Available 12 mg 5 mL = 6 mL 10 mg DIF: Cognitive Level: Applying REF: MCS: 174 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. A child receiving morphine sulfate (Morphine) is experiencing respiratory depression. A health care provider prescribes naloxone (Narcan), 0.5 mcg/kg IV in 2-minute increments until breathing improves. The medication label states: Naloxone 400 mcg/1 mL. The child weighs 40 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places. ANS: 0.05 Follow the formula for dosage calculation. Multiply 0.5 mcg 40 kg to get the dose = 20 mcg Desired Volume = mL per dose Available 20 mcg 1 mL = 0.05 mL 400 mcg DIF: Cognitive Level: Applying REF: MCS: 176 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5. A health care provider prescribes haloperidol (Haldol), 0.15 mg/kg IV every 4 to 6 hours as needed for confusion. The medication label states: Haloperidol 2 mg/1 mL. The child weighs 30 kg. The nurse prepares to administer one dose. How many milliliters will the enuprs repare to administer one dose? Fill in the blank. Record your answer rounding to one decimal place. ANS: 2.3 Follow the formula for dosage calculation. Multiply 0.15 mg 30 kg to get the dose = 4.5 mg Desired Volume = mL per dose Available 4.5 mg 1 mL = 2.25 mL = rounded to one decimal space = 2.3 mL 2 mg DIF: Cognitive Level: Applying REF: MCS: 175 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. A health care provider prescribes Kytril (granisetron), 10 mcg/kg IV every 4 to 6 hours as needed for nausea. The medication label states: Kytril 100 mcg/1 mL. The child weighs 15 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place. ANS: 1.5 Follow the formula for dosage calculation. Multiply 10 mcg 15 kg to get the dose = 150 mcg Desired Volume = mL per dose Available 150 mcg 1 mL = 1.5 mL 100 mcg DIF: Cognitive Level: Applying REF: MCS: 174 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. A health care provider prescribes OxyContin (oxycodone), 3 mg PO every 4 to 6 hours as needed for pain. The medication label states: OxyContin 5 mg/1 mL. The nurse prepares to administer one dose. How many milliliters will the enuprrs the blank. Record your answer using one decimal place. epare to administer one dose? Fill in ANS: 0.6 Follow the formula for dosage calculation. Desired Volume = mL per dose Available 3 mg 1 mL = 0.6 mL 5 mg DIF: Cognitive Level: Applying REF: MCS: 172 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 8. A health care provider prescribes acetaminophen (Tylenol) gtt, 10 mg/kg/dose PO every 4 to 6 hours as needed for pain. The infant weighs 8 kg. The medication label states: Acetaminophen 80 mg/0.8 mL. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place. ANS: 0.8 Follow the formula for dosage calculation. Multiply 10 mg 8 kg to get the dose = 80 mg Desired Volume = mL per dose Available 80 mg 0.8 mL = 0.8 mL 80 mg DIF: Cognitive Level: Applying REF: MCS: 171 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 9. A health care provider prescribes naproxen (Naprosyn), 7 mg/kg PO every 12 hours for pain. The child weighs 25 kg. The medication label states: Naproxen 125 mg/5 mL. The nurse prepares to administer one dose. How many milliliters will the enuprrs dose? Fill in the blank. Record your answer in a whole number. epare to administer one ANS: 7 Follow the formula for dosage calculation. Multiply 7 mg 25 kg to get the dose = 175 mg Desired Volume = mL per dose Available 175 mg 5 mL = 7 mL 125 mg DIF: Cognitive Level: Applying REF: MCS: 171 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 10. A health care provider prescribes choline gmnaesium trisalicylate (Trilisate), 15 mg/kg PO every 8 to 12 hours as needed for pain. The child weighs 10 kg. The medication label states: Choline magnesium trisalicylate 500 mg/5 mL. The nurse prepares to administer one dose. How many milliliters will the pnauresetoprae answer to one decimal place. dminister one dose? Fill in the cbolarndky.oRuer ANS: 1.5 Follow the formula for dosage calculation. Multiply 15 mg 10 kg to get the dose = 150 mg Desired Volume = mL per dose Available 150 mg 5 mL = 1.5 mL 500 mg DIF: Cognitive Level: Applying REF: MCS: 171 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity Chapter 6.Childhood Communicable and Infectious Diseases MULTIPLE CHOICE 1. Pertussis vaccination should begin at which age? a. Birth b. 2 months c. 6 months d. 12 months ANS: B The acellular ptuesrsis vaccine is recommended bAymtheerican A cademy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. Te hvaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to pertussis, which can be a life-threatening illness in this age group. DIF: Cognitive Level: Understanding REF: MCS: 209 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. A mother tells the nurse that she does not want her infant immunized because of eth discomfort associated with injections. What should the nurse explain? a. This cannot be prevented. b. Infants do not feel pain as adults do. c. This is not a good reason for refusing immunizations. d. A topical anesthetic can be applied before injections are given. ANS: D To minimize the discomfort associated with intramuscular injections, a topical anesthetic agent can be used on the injection site. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. Infants have neural pathways that will indicate pain. Numerous researchisetsuhdave indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process. DIF: Cognitive Level: Analyzing REF: MCS: 207 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 3. A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine). She is recovering from a cold but is otherwise healthy and ailfee.bHr er older sister has cancer and is receiving chemotherapy. Nursing considerations should include which? a. DTaP and IPV can be safely given. b. DTaP and IPV are contraindicated because she has a cold. c. IPV is contraindicated because her sister is immunocompromised. d. DTaP and IPV are contraindicated because her sister is immunocompromised. ANS: A These immunizations can be given safely. Serious illness is a contraindication. A mild illness with or without fever is not a contraindication. These are not live vaccines, so they do not pose a risk to her sister. DIF: Cognitive Level: Analyzing REF: MCS: 202 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 4. Which serious reaction should the nurse be alert for when administering vaccines? a. Fever b. Skin irritation c. Allergic reaction d. Pain at injection site ANS: C Each vaccine administration carries the risk of an allergic reaction. The nurse must be prepared to intervene if the child demonstrates signs of a severe reaction. Mild fileebreactions do occur after administration. The nurse includes management of fever in the parent teaching. Local skin irritation may occur at the injection site after administration. Parents are informed that this is expected. The injection can be painful. The nurse can minimize the discomfort with topical analgesics and nonpharmacologic measures. DIF: Cognitive Level: Understanding REF: MCS: 209 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 5. Which muscle is contraindicated for the administration of immunizations in infants and young children? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Anterolateral thigh ANS: B The dorsogluteal site is avoided in children because of the location of nerves and veins. The deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants. DIF: Cognitive Level: Understanding REF: MCS: 196 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 6. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid? a. Cyst b. Papule c. Pustule d. Vesicle ANS: D A vesicle is elevated, cuirmscribed, superficial, smaller than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A peaips uellevated; palpable; firm; circumscribed; smaller than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid. DIF: Cognitive Level: Understanding REF: MCS: 204 TOP: Nursing Process: Assessment :MCSlCient Needs: Physiological Integrity 7. Which vitamin supplementation has been found to reduce both morbidity and mortality in measles? a. A b. B1 c. C d. Zinc ANS: A Evidence suggests that vitamin A supplementation reduces both morbidity and mortality in measles. DIF: Cognitive Level: Understanding REF: MCS: 203 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. What does impetigo ordinarily results in? a. No scarring b. Pigmented spots c. Atrophic white scars d. Slightly depressed scars ANS: A Impetigo tends to heal without scarring unless a secondary infection occurs. DIF: Cognitive Level: Understanding REF: MCS: 227 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. What often causes cellulitis? a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococci or staphylococci ANS: D Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C. albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with various types of human warts. DIF: Cognitive Level: Understanding REF: MCS: 227 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. Lymphangitis (streaking) is frequently seen in what? a. Cellulitis b. Folliculitis c. Impetigo contagiosa d. Staphylococcal scalded skin ANS: A Lymphangitis is frequently seen in cellulitis. If it is spernet, h for parenteral antibiotics. Lymphangitis is not associatedtwh if staphylococcal scalded skin. DIF: Cognitive Level: Understanding REF: MCS: 227 poitsalization is usually required lioclulitis, im petigo, or TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. What is most important in the management of cellulitis? a. Burow solution compresses b. Oral or parenteral antibiotics c. Topical application of an antibiotic d. Incision and drainage of severe lesions ANS: B Oral or parenteral antibiotics are indicated depending on the extent of the cellulitis. Warm water compresses may be indicated for limited cellulitis. The antibiotic needs to be administered systemically. Incision and drainage of severe lesions presents a risk of spreading infection or making the lesion worse. DIF: Cognitive Level: Analyzing REF: MCS: 227 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. What causes warts? a. A virus b. A fungus c. A parasite d. Bacteria ANS: A Human warts are caused by the human papillomavirus. Infection with fungus, parasites, or bacteria does not result in warts. DIF: Cognitive Level: Understanding REF: MCS: 228 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. What is the apryimt reatment for warts? a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy ANS: B Local destructive therapy is individualized according to location, type, and number; surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used. Vaccination pishpyrloaxis for warts, not a treatment. Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts. DIF: Cognitive Level: Understanding REF: MCS: 229 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 14. Herpes zoster is caused by the varicella virus and has an affinity for which? a. Sympathetic nerve fibers b. Parasympathetic nerve fibers c. Lateral and dorsal columns of the spinal cord d. Posterior root ganglia and posterior horn of the spinal cord ANS: D The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the spinal cord, and the skin. The zoster virus does not involve the nerve fibers listed. DIF: Cognitive Level: Understanding REF: MCS: 229 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 15. Treatment for herpes simplex virus (type 1 or 2) includes which? a. Corticosteroids b. Oral griseofulvin c. Oral antiviral agent d. Topical or systemic antibiotic ANS: C Oral antiviral agents are effective for evcirtaiol ninsfsuch as herpes simplex. Corticosteroids, antibiotics, and griseofulvin (an antifungal agent) are not effective for viral infections. DIF: Cognitive Level: Understanding REF: MCS: 229 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16. What should the nurse explain about ringworm? a. It is not contagious. b. It is a sign of uncleanliness. c. It is expected to resolve spontaneously. d. It is spread by both direct and indirect contact. ANS: D Ringworm is spread by both direct and indirect contact. Infected children should wear protective caps at night to avoid transfer of ringworm to bedding. Ringworm is infectious.eBecaus ringworm is easily transmitted, it is not a sign of uncleanliness. It can be transmitted by seats with head rests, gym mats, and animal-to-human transmission. The drug griseofulvin is indicated for a prolonged course, possibly several months. DIF: Cognitive Level: Understanding REF: MCS: 228 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 17. When giving instructions to a parent whose child has scabies, what should the nurse include? a. Treat all family members if symptoms develop. b. Be prepared for symptoms to last 2 to 3 weeks. c. Carefully treat only areas where there is a rash. d. Notify practitioner so an antibiotic can be prescribed. ANS: B The mite responsible for the scabies will most likely be killed with the administration of medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the symptoms will abate. Initiation of therapy does not wait for clinical symptom development. All individuals in close contact with the affected child need to be treated. Permethrin, a scabicide, is the preferred treatment and is applied to all skin surfaces. DIF: Cognitive Level: Analyzing REF: MCS: 233 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 18. Which is usually the only symptom of pediculosis capitis (head lice)? a. Itching b. Vesicles c. Scalp rash d. Localized inflammatory response ANS: A Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized inflammatory response are not symptoms of head lice. DIF: Cognitive Level: Understanding REF: MCS: 234 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 19. The school reviewed the pediculosis capitis (head lice) policy and removed the no nit requirement. The nurse explains that now, when a child is found to have nits, the parents must do which before the child can return to school? a. No treatment is necessary with the policy change. b. Shampoo and then trim the childs hair to prevent reinfestation. c. The child can remain in school with treatment done at home. d. Treat the child with a shampoo to treat lice and comb with a fine-tooth comb every day until nits are eliminated. ANS: C Many children have missed significant amounts of school time with no nit policies. The child should be appropriately treated with a pediculicide and a fine-tooth comb. The environment needs to be treated to prevent reinfestation. The treatment with the pediculicide will kill the lice and leave nit casings. Cutting the childs hair is not recommended; lice infest short hair as well as long. With a no nit policy, treating the child with a shampoo to treat lice and combing the hair with a fine-tooth comb every day until nits are eliminated is the correct treatment. The policy change recognizes that most nits do not become lice. DIF: Cognitive Level: Understanding REF: pp. 235-236 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 20. The nurse should know what about Lyme disease? a. Very difficult to prevent b. Easily treated with oral antibiotics in stages 1, 2, and 3 c. Caused by a spirochete that enters the skin through a tick bite d. Common in geographic areas where the soil contains the mycotic spores that cause the disease ANS: C Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve shirts and long pants tucked into socks should be the attire. Early treatment of erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores. DIF: Cognitive Level: Understanding REF: MCS: 236 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 21. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for furtahcehrinteg? a. I will use precautions when I give an infant oral care. b. I will use precautions when I change an infants diaper. c. I will use precautions when I come in contact with blood and body fluids. d. I will use precautions when administering oral medications to a school-age child. ANS: D Standard precautions involve the use of barrier protection (personal protective equipment [PPE]), such as gloves, goggles, a gown, or a mask, to prevent contamination from (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood; (3) nonintact skin; and (4) mucous membranes. Precautions should be taken when giving oral care, when changing diapers, and when coming in contact with blood and body fluids. Further teaching is needed if the student indicates the need to use precautions when administering an oral medication to a school-age child. DIF: Cognitive Level: Applying REF: MCS: 193 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n2t.eTgrhietynurse is preparing an airborne infection isolation room for a patient. Which communicable disease does the patient likely have? a. Varicella b. Pertussis c. Influenza d. Scarlet fever ANS: A An airborne infection isolation room is the isolation for persons with a suspected or confirmed airborne infectious disease transmitted by tahireborne rout e such as measles, varicella, or tuberculosis. Pertussis, influenza, and scarlet fever require droplet transmission precautions. DIF: Cognitive Level: Applying REF: MCS: 194 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 23. An infant with respiratory syncytial virus (RSV) is being admitted to the hospital. The nurse should plan to place the infant on which precaution? a. Enteric b. Airborne c. Droplet d. Contact ANS: D A patient with RSV is placed on contact precautions. The transmission of RSV is by contact of secretions, not by droplets or airborne. Enteric precautions are not required for RSV. DIF: Cognitive Level: Applying REF: MCS: 194 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 24. The enuisrsa dministering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination? a. After 2 months b. After 3 months c. After 4 months d. After 6 months ANS: D Hepatitis A vaccine is now recommended for all children beginning at age 1 year (i.e., 12 months to 23 months). The second dose in the two-dose series may be administered no sooner than 6 months after the first dose. DIF: Cognitive Level: Analyzing REF: MCS: 201 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 25. The nurse is preparing to nadismteir a measles, m umps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine? a. The child has recently been exposed to an infectious disease. b. The child has symptoms of a cold but no fever. c. The child is having intermittent episodes of diarrhea. d. The child has a disorder that causes a deficient immune system. ANS: D The MMRV (measles, mumps, rubella, and varicella) vaccine is an attenuated live virus vaccine. Children with deficient immune systems should not ereivce the MMRV vaccine because of a lack of evidence of its safety in this population. Exposure to an infectious disease, symptoms of a cold, or intermittent episodes of diarrhea are not contraindications to receiving a live vaccine. DIF: Cognitive Level: Analyzing REF: MCS: 203 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 26. An immunocompromised child has been exposed to chickenpox. What should the nurse anticipate to be prescribed to the exposed child? a. Acyclovir (Zovirax) b. Valacyclovir (Valtrex) c. Amantadine (Symmetrel) d. Varicella-zoster immune globulin ANS: D The use of ivcaerlla-zoster immune globulinmormiune ignloibnul travenous (IGIV) is recommended for children who are immunocompromised, who have no previous history of varicella, and who iakrelly t orcaocnt the disease and have complications as a result. The antiviral agent acyclovir (Zovirax) or valacyclovir may be used to treat varicella infections in susceptible immunocompromised persons. It is effective in decreasing the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. Symmetrel is an antiviral used to treat influenza. DIF: Cognitive Level: Applying REF: MCS: 212 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 27. The clinic nurse is instructing parents about caring for a tohdadslcearriwasi is (c ommon roundworm). Which statement made by the parents indicates a need for further teaching? a. We will wash our hands often, especially after diaper changes. b. We know that roundworm can be transmitted from person to person. c. We will be sure to continue the nitazoxanide (Alinia) orally for 3 days. d. We will bring a stool sample to the clinic for examination in 2 weeks. ANS: B Ascariasis (common roundworm) is transferred htobtyhewmayouotf contaminated food, fingers, or toys. Further teaching is needed if parents state it is transmitted from person tospoenr. Frequent handwashing, especially after diaper changes, continuing the Alinia for 3 days, and reexamining the stool in 2 weeks are appropriate actions. DIF: Cognitive Level: Analyzing REF: MCS: 224 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. The nurse is assessing a child suspected of having pinworms. Which is the most common symptom the nurse expects to assess? a. Restlessness b. Distractibility c. Rectal discharge d. Intense perianal itching ANS: D Intense perianal itching is the principal symptom of pinworms. Restlessness and distractibility may be nonspecific symptoms. Rectal discharge is not a symptom of pinworms. DIF: Cognitive Level: Understanding REF: MCS: 226 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 29. A child has been diagnosed with giardiasis. Which prescribed medication should the nurse expect to administer? a. Acyclovir (Zovirax) b. Metronidazole (Flagyl) c. Erythromycin (Pediazole) d. Azithromycin (Zithromax) ANS: B Metronidazole is an antibiotic effective against anaerobic bacteria and certain parasites. It is prescribed to treat giartdhiarosims.aZxiis a n antibiotic frequently used to treat respiratory infections. Zovirax is an antiviral medication and Pediazole is an antibiotic used to treat respiratory and skin infections. DIF: Cognitive Level: Applying REF: MCS: 223 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 30. A child has been diagnosed with scabies. Which statement by the parent indicates understanding of the nurses teachingeasb?out scabi a. The itching will stop after the cream is applied. b. We will complete extensive aggressive housecleaning. c. We will apply the cream to only the affected areas as directed. d. Everyone who has been in close contact with my child will need to be treated. ANS: D Because of the length of time between infestation and physical symptoms (30 to 60 days), all persons who were in close contact with the affected child need treatment. Families need to know that although the mite ewkilil b lled, the hrasand the itch will not be ieml inated unt il the tsutrma corneum is replaced, which takes approximately 2 to 3 weeks. Aggressive housecleaning is not necessary, but surface vacuuming of heavily used rooms by a tphercsrounstwedi scabies is recommended. The prescribed cream should be thoroughly and gently massaged into all skin surfaces (not just the areas that have a rash) from the head to the soles of the feet. DIF: Cognitive Level: Analyzing REF: MCS: 232 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 31. An 18-month-old child has been diagnosedtwh ipe diculosis capitis (head lice). Which prescription should the nurse question if ordered for the child? a. Malathion (Ovide) b. Permethrin 1% (Nix) c. Benzyl alcohol 5% lotion d. Pyrethrin with piperonyl butoxide (RID) ANS: A The nurse should question malathion for an 18-month-old child. Malathion contains flammable alcohol, must remain in contact with the scalp for 8 to 12 hours, and is not recommended for children younger than 2 years of age. The drug of choice for infants and children is permethrin 1% cream rinse (Nix) or pyrethrin with piperonyl butoxide, which kill adult lice and nits. Benzyl alcohol 5% lotion has been approved by the Food and Drug Administration for the treatment of head lice in children as young as 6 months. DIF: Cognitive Level: Applying REF: MCS: 234 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 32. A child has been diagnosed with cat scratch disease. The nurse explains which characteristics about itsh disease? a. The disease is usually a benign, self-limiting illness. b. The animal that transmitted the disease will also be ill. c. The disease is treated with a 5-day course of oral azithromycin. d. Symptoms include pruritus, especially at the site of inoculation. ANS: A The disease is usually a benign, self-limiting illness that resolves spontaneously in 4 to 6 weeks. The manails a re not ill during the time they transmit the disease. Treatment is primarily supportive. Antibiotics do not shorten the duration or prevent progression to suppuration. The usual manifestation is a painless, nonpruritic erythematous papule at the site of inoculation. DIF: Cognitive Level: Applying REF: MCS: 239 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is planning care for tahcchhilidckweni pox (varicella). Which prescribed supportive measures should the nurse plan to implement? (Select all that apply.) a. Administration of acyclovir (Zovirax) b. Administration of azithromycin (Zithromax) c. Administration of Vitamin A supplementation d. Administration of acetaminophen (Tylenol) for fever e. Administration of diphenhydramine (Benadryl) for itching ANS: A, D, E Chickenpox is a virus, and acyclovir is ordered to lessen the symptoms. Benadryl and Tylenol are prescribed as supportive treatments. Vitamin A supplementation is used for treating rubeola. Zithromax is an antibiotic prescribed for bacterial infections such as pertussis. DIF: Cognitive Level: Applying REF: MCS: 229 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 2. The enuisrspl anning care faonr infant with candidiasis (moniliasis) diaper dermatitis. Which topical ointments may be prescribed for the patient? (Select all that apply.) a. Nystatin b. Bactroban c. Neosporin d. Miconazole e. Clotrimazole ANS: A, D, E Candidiasis diaper dermatitis skin lseions are treated wthitopical ny statin, miconazole, and clotrimazole. Bactroban and Neosporin are used to treat bacterial dermatitides. DIF: Cognitive Level: Applying REF: MCS: 231 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. The nurse is conducting discharge teaching to an adolescent with a methicillin-resistant staphylococcus aureus (MRSA) infection. What should the nurse include in the instructions? (Select all that apply.) a. Avoid sharing of towels and washcloths. b. Launder clothes and bedding in cold water. c. Use bleach when laundering towels and washcloths. d. Take a daily bath or shower with an antibacterial soap. e. Apply mupirocin (Bactroban) to the nares twice a day for 2 to 4 weeks. ANS: A, D, E For MRSA infection, the adolescent should be provided with washcloths and towels separate from those of other family members. Daily bathing or showering with an antibacterial soap is also recommended. Mupirocin should be applied to the nares of those with MRSA infection twice daily for 2 to 4 weeks. Clothing should be laundered in warm to hot water, not cold, and bleach does not need to be used when laundering towels and washcloths. DIF: Cognitive Level: Applying REF: MCS: 226 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. The icclinur se is reviewing the immunization guidelines for hepatitis B. Which are true of the guidelines for athcicsinve? (Select all that apply.) a. The hepatitis B vaccination series should be begun at birth. b. The adolescent not vaccinated at birth does not have a need to be vaccinated. c. Any child not vaccinated at birth should receive two doses at least 4 months apart. d. An unimmunized 10-year-old child should receive three doses administered 4 weeks apart. ANS: A, D Current immunization guidelines for hepatitis B vaccination recommend beginning the hepatitis B vaccine series at birth or, in unimmunized children, as soon as possible. Children younger than 11 years of age may be vaccinated witheastehrries-,daodsministered 4 w eeks apart. Children 11 years and older may receive the two-dose adult formulation given at least 4 months apart. DIF: Cognitive Level: Analyzing REF: MCS: 196 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is planning to administer immunizations to a 6-month-old infant. Which interventions should the nurse implement to minimize local reactions from tvhaeccines? (Select all that apply.) a. Select a needle length of 1 inch. b. Administer in the deltoid muscle. c. Inject the vaccine into the vastus lateralis. d. Draw the vaccine up from a vial with a filter needle. e. Change the needle on the syringe after drawing up the vaccine and before injecting. ANS: A, C To minimize local reactions from vaccines, the nurse should select a needle of adequate length (25 mm [1 inch] in infants) to deposit the antigen deep in the muscle mass and inject it into the vastus lateralis muscle. The deltoid may be used in children 18 months of age or older but not in a 6-month-old infant. A filter needle is not needed to draw the vaccine from a vial. Changing the needle on the syringe after drawing up the vaccine before injecting it has not been shown to decrease local reactions. DIF: Cognitive Level: Analyzing REF: MCS: 207 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 6. The nurse is preparing to admit a 5-year-old child who developed lesions of varicella (chickenpox) 3 days ago. Which clinical manifestations of varicella should the nurse expect to observe? (Select all that apply.) a. Nonpruritic rash b. Elevated temperature c. Discrete rose pink rash d. Vesicles surrounded by an erythematous base e. Centripetal rash in all three stages (papule, vesicle, and crust) ANS: B, D, E The clinical manifestations of varicella include elevated temperature, vesicles surrounded by an erythematous base, and a centripetal rash inlatl hree stages (papule,ivclees, and cr ust). The rash is pruritic, and a discrete pink rash is seen with exanthema subitum, not varicella. DIF: Cognitive Level: Applying REF: MCS: 212 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. The nurse is preparing to admit a 1-year-old child with pertussis (whooping cough). Which clinical manifestations of pertussis should the nurse expect to observe? (Select all that apply.) a. Earache b. Coryza c. Conjunctivitis d. Low-grade fever e. Dry hacking cough ANS: B, D, E The clinical manifestations of pertussis include coryza, a low-grade fever, and a dry hacking cough. The child does not have an earache or conjunctivitis. DIF: Cognitive Level: Applying REF: MCS: 214 TOP: Nursing Process: Assessment :MCSC ielnt Needs: Physiological Integrity 8. The nurse is preparing to admit a 2-year-old child with rubella (German measles). Which clinical manifestations of rubella should the nurse expect to observe? (Select all that apply.) a. Sore throat b. Conjunctivitis c. Koplik spots d. Lymphadenopathy e. Discrete, pinkish red maculopapular exanthema ANS: A, B, D, E The clinical manifestations of rubella include a sore throat; conjunctivitis; lymphadenopathy; and a discrete, pinkish red maculopapular exanthema. Koplik spots occur in measles but not rubella. DIF: Cognitive Level: Applying REF: MCS: 217 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 9. The clinic nurse is assessing a child with bacterial conjunctivitis (pink eye). Which assessment findings should the nurse expect? (Select all that apply.) a. Itching b. Swollen eyelids c. Inflamed conjunctiva d. Purulent eye drainage e. Crusting of eyelids in the morning ANS: B, C, D, E The assessment findings in bacterial conjunctivitis include swollen eyelids, inflamed conjunctiva, purulent eye drainage, and crusting of eyelids in the morning. Itching is seen with allergic conjunctivitis but not with bacterial conjunctivitis. Chapter 7.Health Promotion of the Newborn and Family MULTIPLE CHOICE 1. What is a function of brown adipose tissue (BAT) in newborns? a. Generates heat for distribution to other parts of body b. Provides ready source of calories in the newborn period c. Protects newborns from injury during the birth process d. Insulates the body against lowered environmental temperature ANS: A Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas should not protect the newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat. DIF: Cognitive Level: Understanding REF: MCS: 244 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 2. Which characteristic is representative of a full-termbornnesw tgraosintestinal tract? a. Transit time is diminished. b. Peristaltic waves are relatively slow. c. Pancreatic amylase is overproduced. d. Stomach capacity is very limited. ANS: D Newborns require frequent small feedings because their stomach capacity is very limited. A newborns colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats. DIF: Cognitive Level: Understanding REF: MCS: 245 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. Which term is used to describe a newborns first stool? a. Milia b. Milk stool c. Meconium d. Transitional ANS: C Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is a newborns first stool. Milia involves distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the newborn is breast or formula fed. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium. DIF: Cognitive Level: Understanding REF: MCS: 245 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. In term newborns, the first meconium stool should occur no later than within how many hours after birth? a. 6 b. 8 c. 12 d. 24 ANS: D The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very lowbirth-weight newborns. DIF: Cognitive Level: Understanding REF: MCS: 245 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. Which is true regarding an infants kidney function? a. Conservation of fluid and electrolytes occurs. b. Urine has color and odor similar to the urine of adults. c. The ability to concentrate urine is less than that of adults. d. Normally, urination does not occur until 24 hours after delivery. ANS: C At birth, all structural components are present in the renal system, but rtheeis a functional deficiency in the kidneys ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day. DIF: Cognitive Level: Understanding REF: MCS: 245 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 6. The rAspcgoare of an infant 5nmuties a of this? tefr birth is 8. Which is the nurses best interpretation a. Resuscitation is likely to be needed. b. Adjustment to extrauterine life is adequate. c. Additional scoring in 5 more minutes is needed. d. Maternal sedation or analgesia contributed to the low score. ANS: B The Apgar reflects an infants status in five areas: heart aratoter,yrefsfpoirt, m uscle tone, reflex irritability, and color. oArescof 8 to 10 indicates an absence of difficulty adjusting to extrauterine life. Scores of 0 toc3atiendsei ver e distress, and scores of 4 toc7atindi e moderate difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of distress; the newborn does not have a low score. The Apgar score is not used to determine the infants need for resuscitation at birth. DIF: Cognitive Level: Understanding REF: MCS: 247 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. Which statement best represents the first stage or the first period of reactivity in the infant? a. Begins when the newborn awakes from a deep sleep b. Is an excellent time to acquaint the parents with the newborn c. Ends when the amounts of respiratory mucus have decreased d. Provides time for the mother to recover from the childbirth process ANS: B During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping. DIF: Cognitive Level: Applying REF: MCS: 247 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. Which statement lrecfts accurate information about tpeartns of sleep andfwulankeess in t eh newborn? a. States of sleep are independent of environmental stimuli. b. The quiet alert stage is the best stage for newborn stimulation. c. Cycles of sleep states are uniform in newborns of the same age. d. Muscle twitches and irregular breathing are common during deep sleep. ANS: B During the quiet alert stage, the newborns eyes are wide open and bright. bTohrennrewsponds to the environment by active body movement and staring at close-range objects. Newborns ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep. DIF: Cognitive Level: Analyzing REF: MCS: 249 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 9. The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do? a. Ask the mother why she wont look at the infant. b. Examine the infants eyes for the ability to focus. c. Assess the mother for other attachment behaviors. d. Recognize this as a common reaction in new mothers. ANS: C Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the ainnft is a c nofrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers. DIF: Cognitive Level: Applying REF: MCS: 249 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Which should the nurse use when assessing the physical maturity of a newborn? a. Length b. Apgar score c. Posture at rest d. Chest circumference ANS: C With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest cuirmference reflect t he newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life. DIF: Cognitive Level: Applying REF: MCS: 251 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 11. What is the grayish white, cheeselike substance that covers tnhewborns skin? a. Milia b. Meconium c. Amniotic fluid d. Vernix caseosa ANS: D The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin. DIF: Cognitive Level: Remembering REF: MCS: 260 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 12. What is most descriptive of the shape of the anterior fontanel in a newborn? a. Circle b. Square c. Triangle d. Diamond ANS: D The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square. DIF: Cognitive Level: Remembering REF: MCS: 261 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent? a. Acrocyanosis b. Mongolian spots c. Erythema toxicum d. Harlequin color change ANS: B Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale. DIF: Cognitive Level: Understanding REF: MCS: 254 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 14. The nurse should expect the apical heart rate of a stabilized newborn to be in which range? a. 60 to 80 beats/min b. 80 to 100 beats/min c. 120 to 140 beats/min d. 160 to 180 beats/min ANS: C The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180 beats/min is too fast for a newborn. DIF: Cognitive Level: Understanding REF: MCS: 259 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 15. Which finding in the newborn is considered abnormal? a. Nystagmus b. Profuse drooling c. Dark green or black stools d. Slight vaginal reddish discharge ANS: B Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge. DIF: Cognitive Level: Understanding REF: MCS: 256 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 16. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as? a. A hydrocele b. An inguinal hernia c. A normal finding d. An absence of testes ANS: C A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or saebnce of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia. DIF: Cognitive Level: Understanding REF: MCS: 257 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 17. Why eacretarl t emperatures not recommended inbnoerwns? a. They are inaccurate. b. They do not reflect core body temperature. c. They can cause perforation of rectal mucosa. d. They take too long to obtain an accurate reading. ANS: C Rectal temperatures are avoided in newborns. If done rinreccotly, the insertion of a thermometer into the rectum can cause perforation of the mucosa. The time it takes to determine body temperature is related to the equipment used, not only the route. DIF: Cognitive Level: Understanding REF: MCS: 259 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 18. Which is the name of the suture separating the parietal bones at the top of a newborns head? a. Frontal b. Sagittal c. Coronal d. Occipital ANS: B The sagittal suture separates the parietal bones at the top of the newborns head. The frontal suture separates the frontal bones. The coronal suture is said to crown the head. The lambdoid suture is at the margin of the parietal and occipital. DIF: Cognitive Level: Understanding REF: MCS: 261 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 19. The nurse observes flaring of nares in a newborn. What should this be interpreted as? a. Nasal occlusion b. Sign of respiratory distress c. Snuffles of congenital syphilis d. Appropriate newborn breathing ANS: B Nasal flaring is an indication of respiratory tdriesss. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring. DIF: Cognitive Level: Understanding REF: MCS: 255 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 20. The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex? a. Grasp b. Perez c. Babinski d. Dance or step ANS: C This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by htoinugc the palms or esobleaseatofth the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surfearecei, th s a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks. DIF: Cognitive Level: Understanding REF: MCS: 266 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 21. Which is most important in the immediate care of the newborn? a. Maintain a patent airway. b. Administer prophylactic eye care. c. Maintain a stable body temperature. d. Establish identification of the mother and baby. ANS: A Maintaining a patent airway is the primary objective in the care of the newborn. First, the pharynx is cleared with a bulb syringe followed by the nasal passages. Administering prophylactic eye care and establishing identification of the mother and baby are important functions, but physiologic stability is the first priority in the immediate care of the newborn. Conserving the newborns body heat and maintaining a stable body temperature are important, but a patent airway must be established first. DIF: Cognitive Level: Analyzing REF: MCS: 267 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 22. What should nursing interventions to maintain a patent airway in a newborn include? a. Positioning the newborn supine after feedings. b. Wrapping the newborn as snugly as possible. c. Placing the newborn to sleep in the prone (on abdomen) position. d. Using a bulb syringe to suction as needed, suctioning the nose first and then the pharynx. ANS: A Positioning the newborn supine after feedings is recommended by the American Academy of Pediatrics to prevent sudden newborn death syndrome. The child can be wrapped snugly but should be placed on the side or back. Placing a newborn to sleep in the prone (on abdomen) position is not advised because of the possible link between sleeping in the prone position and sudden newborn death syndrome. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose. DIF: Cognitive Level: Applying REF: MCS: 267 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23. The nurse quickly dries the newborn after delivery. This is to conserve the newborns body heat by preventing heat loss through which method? a. Radiation b. Conduction c. Convection d. Evaporation ANS: D Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid. Radiation is the loss of heat to a cooler solid object. The rcofrldomai e ither the window or the air conditioner will cool the walls of the incubator and subsequently the body of the newborn. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is similar to conduction but is the loss of heat aided by air currents. DIF: Cognitive Level: Applying REF: MCS: 267 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 24. An infant is being discharged at 48 hours of age. The parents ask how the infant should be bathed this first week home. Which is the best recommendation by the nurse? a. Bathe the infant daily with mild soap. b. Bathe the infant daily with an alkaline soap. c. Bathe the infant two or three times this week with mild soap. d. Bathe the infant two or three times this wk eweith plain water. ANS: D A newborn infants skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the infant no more than two or three times the first 2 weeks. pSsoa are alkaline. They will alter the acid nmtlea of the infants skin, providing a medium for bacterial growth. DIF: Cognitive Level: Applying REF: MCS: 271 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 25. The stump of the umbilical cord usually drops off in how many days? a. 3 to 6 b. 10 to 14 c. 16 to 21 d. 24 to 28 ANS: B The average umbilical cord separates in 10 to 14 days. Three to 6 days is too soon, and 16 to 28 days is too late. DIF: Cognitive Level: Understanding REF: MCS: 271 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 26. The parents of an infant plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurses response should be based on which? a. That infants experience pain with circumcision b. That infants are too young for anesthesia or analgesia c. That infants do not experience pain with circumcision d. That infants quickly forget about the pain of circumcision ANS: A Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that procedural analgesia be provided when circumcision is performed. The pain infants experience with surgical procedures can be alleviated with analgesia. Infants who undergo circumcision without anesthetic agents react more intensely to immunization injections at 4 to 6 months of age compared with infants who had an anesthetic. DIF: Cognitive Level: Applying REF: MCS: 272 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n7t.eTgrhietynurse is teaching a class on breastfeeding to expectant parents. Which is a contraindication for breastfeeding? a. Mastitis b. Twin births c. Inverted nipples d. Maternal cancer therapy ANS: D Mothers receiving chemotherapy with antimetabolites and certain antineoplastic drugs should not breastfeed. The drugs are passed to the newborn through the breast milk. Mastitis, twin births, and inverted nipples are not contraindications. DIF: Cognitive Level: Applying REF: MCS: 277 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. Successful breastfeeding is most dependent on which? a. Birth weight of newborn b. Size of mothers breasts c. Mothers desire to breastfeed d. Familys socioeconomic level ANS: C The factors that contribute to successful breastfeeding are the mothers desire to breastfeed, satisfaction with breastfeeding, and available support systems. Very lowbirth-weight infants may be unable to breastfeed. The mother can express milk, and it can be used for the infant. The size of mothers breasts does not eacfft the success of breastfeeding. The familys socioeconomic level may affect the mothers need to return to work and available support systems, but with support, the mother can be successful. DIF: Cognitive Level: Applying REF: MCS: 279 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 29. A mother who breastfeeds her 6-week-old infant every 4 hours tells the nurse that hs e seem hungry all the time. The nurse should recommend which? a. Newborn cereal b. Supplemental formula c. More frequent feedings d. No change in feedings ANS: C Infants who are breastfed tend to be hungry every 2 to 3 hours. They should be fed frequently. Six weeks is too early to introduce newborn cereal. Supplemental formula is not indicated. Giving additional formula or water to a breastfed infant may satiate the infant and create problems with breastfeeding. The infant requires additional feedings. Four hours is too long between feedings for a breastfed infant. DIF: Cognitive Level: Applying REF: MCS: 279 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 30. What should a nursing intervention to promote parentinfant attachment include? a. Encouraging parents to hold the infant frequently unless the infant is fussy b. Explaining individual differences among infants to the parents c. Delaying parentinfant interactions until the second period of reactivity d. Alleviating stress for parents by decreasing their participation in the infants care ANS: B Nurses can positively influence the attachment of parent and infant by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each infant. The parents should be encouraged to hold the infant when he or she is fussy and learn how best to soothe their infant. The nurse should facilitate parentinfant interaction during the first period of reactivity. Decreasing the parents participation in care interferes with parentinfant attachment. DIF: Cognitive Level: Applying REF: MCS: 283 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 31. A new mother wants to be discharged with her infant as soon as possible. Before discharge, what should the nurse be certain of? a. The infant has voided at least once. b. The infant does not spit up after feeding. c. Jaundice, if present, appeared before 24 hours. d. A follow-up appointment with the practitioner is made within 48 hours. ANS: D The American Academy of Pediatrics recommends that newborns discharged earlycreeive follow-up care within 48 hours in either a primary practitioners office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is normal in newborns; it should not delay discharge. Jaundice within the first 24 hours of life must be evaluated. DIF: Cognitive Level: Applying REF: MCS: 287 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is teaching new parents about the benefits of breastfeeding their infant. Which statement by the parent should indicate a correct understanding of the teaching? a. I should breastfeed my baby so that she will grow at a faster rate than a bottle-fed newborn. b. One of the advantages of breastfeeding is that the baby will have fewer stools per day. c. I should breastfeed my baby because breastfed babies adapt more easily to a regular schedule of feedings. d. Some of the advantages of breastfeeding are that breast milk is economical and readily available for my baby. ANS: D Some advantages of breastfeeding a newborn are that breast milk is more economical, is readily available, and is sanitary. Breastfed newborns usually grow at a satisfactory, slower rate than bottle-fed newborns, which research indicates aids in decreased obesity in children. Breastfed babies have an increased number of stools throughout a 24-hour period, and neither breastfed nor bottle-fed newborns should be placed on a regular schedule; they should be fed on demand. DIF: Cognitive Level: Applying REF: MCS: 275 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Health Promotion and Maintenance 33. The nurse is caring for a patient who has chosen to breastfeed her infant. Which statement should the nurse include when teaching the mother about breastfeeding problems that may occur? a. If you experience painful nipples, cleanse your nipples with soap two times per day and keep your nipples covered as much as possible. b. If you experience plugged ducts, continue to breastfeed every 2 to 3 hours and alternate feeding positions. c. If mastitis occurs, discontinue breastfeeding while taking prescribed antibiotics and apply warm compresses. d. If engorgement occurs, use cold compresses before a feeding and wear a well- fitting bra at night. ANS: B If a woman experiences plugged ducts, the best interventions are to continue breastfeeding every 2 to 3 hours and alternate feeding positions while pointing the infants chin toward the obstructed area. Other interventions liundce massaging breasts and applying warm pcoremsses before feeding or pumping. If painful nipples occur, the woman should avoid soaps, oils, and lotions and air the nipples as much as possible. If mastitis occurs, the woman shouldncuoenti breastfeeding to keep the breast well drained. If engorgement occurs, the woman should use a warm compress before feedings and wear a well-fitting bra 24 hours a day. DIF: Cognitive Level: Analyzing REF: MCS: 281 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is completing a physical and gestational age assessment on an infant who is 12 hours old. Which components are included in the gestational age assessment? (Select all that apply.) a. Arm recoil b. Popliteal angle c. Motor performance d. Primitive reflexes e. Square window f. Scarf sign ANS: A, B, E, F The components of the typical gestational age assessment liundce posture, squeawinrdow, ar m recoil, popliteal angle, scarf sign, and heel to ear. Motor pfoerrmance and reflexes are parts of the behaviors in the Brazelton Neonatal Behavioral Assessment Scale. DIF: Cognitive Level: Applying REF: MCS: 250 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. The nurse is teaching parents about the visual ability of their newborn. Which should the nurse include in the teaching session? (Select all that apply.) a. Visual acuity is between 20/100 and 20/400. b. Tear glands do not begin to function until 8 to 12 weeks of age. c. Infants can momentarily fixate on a bright object that is within 8 inches. d. The infant demonstrates visual preferences of black-and-white contrasting patterns. e. The infant prefers bright colors (red, orange, blue) over medium colors (yellow, green, pink). ANS: A, C, D Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques. The infant has the ability to momentarily fixate on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. The infant demonstrates visual preferences of black-and-white contrasting patterns. The visual preference is for medium colors (yellow, green, pink) over dim or bright colors (red, orange, blue). Tear glands begin to function until 2 to 4 weeks of age. DIF: Cognitive Level: Applying REF: MCS: 246 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. Which assessments are included in tAhpegar scoring system? (Select all that apply.) a. Heart rate b. Muscle tone c. Blood pressure d. Blood glucose e. Reflex irritability ANS: A, B, E The Apgar score is based on observation of therar ate, respiratoryoerftf, muscle tone, r eflex irritability, and color. Blood pressure and blood glucose are not part of the Apgar scoring system. DIF: Cognitive Level: Analyzing REF: MCS: 247 TOP: NursoicnegssP:rAssessment MSC: Client eNdes: Physiologica l Integrity 4. The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment tnhuerse shoul dmdoencut? (Select all that apply.) a. Periodic breathing b. Respiratory rate of 40 breaths/min c. Wheezes on auscultation d. Apnea lasting 25 seconds e. Slight intercostal retractions ANS: A, B, E Periodic breathing is common in full-term newborns and consists of rapid, nonlabored respirations followed by pauses of less than 20 seconds. The newborns respiratory rate is between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should be reported. Chapter 8.Health Problems of the Newborn MULTIPLE CHOICE 1. Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery? a. Hydrocephalus b. Cephalhematoma c. Caput succedaneum d. Subdural hematoma ANS: C Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum or blood (or both) accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It should not be visible on the scalp. DIF: Cognitive Level: Remembering REF: MCS: 295 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 2. Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture? a. Positive scarf sign b. Asymmetric Moro reflex c. Swelling of fingers on affected side d. Paralysis of affected extremity and muscles ANS: B A newborn with a broken clavicle may have no signs. The Moro reflex, which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities, will most likely be yasmmetric. T he scarf st iigsnutsha ed to determine tgaetsional age s hould not be performed if a broken clavicle is suspected. Swelling of the fingers on the affected side and paralysis of the affected extremity and muscles are not signs of a fractured clavicle. DIF: Cognitive Level: Analyzing REF: MCS: 297 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. The parents of a newborn ask the nurse what caused the babys facial nerve paralysis. The nurses response is based on remembering that this is caused bytw? ha a. Birth injury b. Genetic defect c. Spinal cord injury d. Inborn error of metabolism ANS: A Pressure on the facial nerve (cranial nerve VII) during delivery may result in injury to the nerve. Genetic defects, spinal cord injuries, and inborn errors of metabolism did not cause the facial nerve paralysis. The paralysis usually disappears in a few days but may take as long as several months. DIF: Cognitive Level: Understanding REF: MCS: 297 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is what? a. Easily treated b. Benign and transient c. Usually not contagious d. Usually not disfiguring ANS: B Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The rash usually lasts about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not contagious. Successive crops of lesions heal without pigmentation. DIF: Cognitive Level: Applying REF: MCS: 310 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. What should nursing care of an infant with oral candidiasis (thrush) include? a. Avoid use of a pacifier. b. Continue medication for the prescribed number of days. c. Remove the characteristic white patches with a soft cloth. d. Apply medication to the oral mucosa, being careful that none is ingested. ANS: B The medication must be continued for the prescribed number of days. To prevent relapse, therapy should continue for at least 2 days after the lesions disappear.cPifaier s can be used. The pacifier should be replaced with a new one or boiled for 20 minutes once daily. One of the characteristics of thrush is that the white patches cannot be removed. The medication is applied to the oral mucosa and then swallowed to treat Candida albicansinfection in the gastrointestinal tract. DIF: Cognitive Level: Applying REF: MCS: 310 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 6. A mother brings her 6-week-old infant in with complaints of poor feeding, lethargy, fever, irritability, and a vesicular rash. What does the nurse suspect? a. Impetigo b. Candidiasis c. Neonatal herpes d. Congenital syphilis ANS: C Neonatal herpes is one of the most serious viral infections in newborns, with taamlitoyrra te of up to 60% in infants with disseminated disease. pBeutlilous im go is an infectious superficial skin condition most often caused byStaphylococcus aureus infection. It is characterized by bullous vesicular lesions on previously untraumatized skin. Candidiasis is characterized by ewhit adherent patches on the tongue, palate, and inner aspects of the cheeks. Congenital syphilis has multisystem manifestations, including hepatosplenomegaly, lymphadenopathy, hemolytic anemia, and thrombocytopenia. DIF: Cognitive Level: Analyzing REF: MCS: 310 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. Which is a bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth? a. Port-wine stain b. Juvenile melanoma c. Cavernous hemangioma d. Strawberry hemangioma ANS: D Strawberry hemangiomas (or capillary hemangiomas) are benign cutaneous tumors that involve only capillaries. They are bright red, rubbery nodules with rough surfaces and well-defined margins. They may or may not be apparent at birth but enlarge during the first year of life and tend to resolve spontaneously by ages 2 to 3 years. A port-wine stain is a vascular stain that is a permanent lesion and is present at birth. Initially, it is a pink; red; or, rarely, purple stain of the skin that is flat at birth; it thickens, darkens, and proportionately enlarges as the infant grows. Melanoma is not differentiated into juvenile and adult forms. A cavernous hemangioma involves deeper vessels in the dermis and has a bluish red color and poorly defined margins. DIF: Cognitive Level: Understanding REF: MCS: 312 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 8. What is an infant twhiseve re jaundice at risk for developing? a. Encephalopathy b. Bullous impetigo c. Respiratory distress d. Blood incompatibility ANS: A Unconjugated bilirubin, which can cross the bloodbrain barrier, is highly toxic to neurons. An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Bullous impetigo is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice. DIF: Cognitive Level: Understanding REF: MCS: 314 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant? a. 2 to 12 hours b. 12 to 24 hours c. 2 to 4 days d. After the fifth day ANS: C Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mothers milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake. DIF: Cognitive Level: Understanding REF: MCS: 316 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant? a. Institute early and frequent feedings. b. Bathe newborn when the axillary temperature is 36.3 C (97.5 F). c. Place the newborns crib near a window for exposure to sunlight. d. Suggest that the mother initiate breastfeeding when the danger of jaundice has passed. ANS: A Physiologic jaundice is caused by the immature hepatic function of the newborns liver coupled with the increased load from red blood cell hemolysis. The excess bilirubinofmr t he destroyed red blood cells cannot be excreted from the body. Feeding stimulates peristalsis and produces more rapid passage of meconium. Bathing does not affect physiologic jaundice. Placing the newborns crib near a window for exposure to sunlight is not a treatment of physiologic jaundice. Colostrum is a natural cathartic that facilitates meconium excavation. DIF: Cognitive Level: Applying REF: MCS: 316 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 11. What is an important nursing intervention for a full-term infant receiving phototherapy? a. Observing for signs of dehydration b. Using sunscreen to protect the infants skin c. Keeping the infant diapered to collect frequent stools d. Informing the mother why breastfeeding must be discontinued ANS: A Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a frying effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. Tnthaegeadva to the mother and father of being able to hold their infant outweighs the concerns related to clearance. DIF: Cognitive Level: Applying REF: MCS: 318 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. Rh hemolytic disease is suspected in a mothers second baby, a son. Which factor is important in understanding how this could develop? a. The first child was a girl. b. The first child was Rh positive. c. Both parents have type O blood. d. She was not immunized against hemolysis. ANS: B Hemolytic disease of the newborn results from an abnormally rapid rtea of red blood cell (RBC) destruction. The major causes of this are tmeranalfetal Rh a nd ABO incompatibility. If an Rh- negative mother has previously been exposed to Rh-positive blood through pregnancy or blood transfusion, antibodies to this blood group antigen may develop so that she is isoimmunized. With further exposure to Rh-positive blood, the maternal antibodies agglutinate with the RBCs of the fetus that has the antigen and destroy the cells. Hemolytic disease caused by ABO incompatibilities can be present with the first pregnancy. The gender of the first child is not a concern. Blood type is the important consideration. If both parents have type O blood, ABO incompatibility should not be a possibility. DIF: Cognitive Level: Analyzing REF: MCS: 322 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. When should the nurse expect jaundice to be present in a full-term nintfwa ith he molytic disease? a. At birth b. Within 24 hours after birth c. 25 to 48 hours after birth d. 49 to 72 hours after birth ANS: B In hemolytic disease of the infant, jaundice is usually evident within the first 24 hours of life. Infants with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present. Twenty-five to 72 hours after birth is too late for hemolytic disease of the infant. Jaundice at these ages is most likely caused by physiologic or early-onset breastfeeding jaundice. DIF: Cognitive Level: Understanding REF: MCS: 325 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 14. A woman who is Rh-negative is pregnant with her first child, and her husband is Rh positive. During her 12-week prenatal visit, she tells the nurse that she has been told that this is dangerous. What should the nurse tell her? a. That no treatment is necessary b. That an exchange transfusion will be necessary at birth c. That no treatment is available until the infant is born d. That administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation ANS: D The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh- negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant rsyectonda o the Rh factor. Unless other problems coexist, the newborn will not require transfusions at birth. DIF: Cognitive Level: Analyzing REF: MCS: 323 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 15. The nurse is planning care for an infant receiving calcium gluconate for treatment of hypocalcemia. Which route of administration should be used? a. Oral b. Intramuscular c. Intravenous d. Intraosseous ANS: C Calcium gluconate is administered intravenously over 10 to 30 minutes or as a continuous infusion. If it is given more rapidly than this, cardiac dysrhythmias and circulatory collapse may occur. Early feedings are indicated, but when the ionized calcium drops below 3.0 to 4.4 mg/dL, intravenous calcium gluconate is necessary. Intramuscular or intraosseous administration is not recommended. DIF: Cognitive Level: Applying REF: MCS: 329 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 16. The nurse is caring for an infant who will be discharged on home phototherapy. What instructions should the nurse include in the discharge ctehaing tontthse? pare a. Apply an oil-based lotion to the infants skin two times per day to prevent the skin from drying out under the phototherapy light. b. Keep the eye shields on the infants eyes even when the phototherapy light is turned off. c. Take the infants temperature every 2 hours while the newborn is under the phototherapy light. d. Make a follow-up visit with the health care provider within 2 or 3 days after your infant has been on phototherapy. ANS: D With short hospital stays, infants may be discharged with a prescription for home phototherapy. It is the responsibility of the nurse planning discharge to include important information such as the need for a follow-up visit with the health care provider in 2 or 3 days to evaluate feeding and elimination pattern and to have blood work done if needed. The parents should be taught to not apply oil or lotions to prevent increased tanning; the babys eye shields can come off when the phototherapy lights are turned off, and the infants temperature needs to be monitored but not taken every 2 hours. DIF: Cognitive Level: Applying REF: MCS: 322 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I1n7t.eTgrhietynurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery. The infants blood glucose level is 36 mg/dL. Which action should the nurse implement? a. Bring the infant to the mother and initiate breastfeeding. b. Place a nasogastric tube and administer 5% dextrose water. c. Start a peripheral intravenous line and administer 10% dextrose. d. Monitor the infant in the nursery and obtain a blood glucose level in 4 hours. ANS: A A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dL, and who is clinically asymptomatic should porbably restaeblish no ogrlymcemia w ith early institution of breast or bottle feeding. The newborn does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose because the blood glucose level is only borderline. The infant does need to be monitored, but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours. DIF: Cognitive Level: Applying REF: MCS: 326 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. A pregnant client asks the nurse to explain the meaning of cephalopelvic disproportion. Which explanation should the nurse give to the client? a. It means a large for gestational age fetus. b. It is the narrow opening between the ischial spines. c. There is an uneven size between the fetus presenting part and the pelvis. d. The shape of the pelvis is an android shape and is unfavorable for vaginal delivery. ANS: C Cephalopelvic disproportion means a disproportion (or uneven size) between the fetus presenting part and the maternal pelvis. It does not mean a large for gestational age fetus or that the pelvis is an android shape. The narrow opening between the ischial spines is called the transverse measurement. DIF: Cognitive Level: Applying REF: MCS: 298 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I1n9t.eTgrhietynurse is caring for a newborn with Erb palsy. The nurse understands that which reflex is absent with this condition? a. Root reflex b. Suck reflex c. Grasp reflex d. Moro reflex ANS: D Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus and usually results from stretching or pulling away of the shoulder from the head. The Moro reflex is absent in a newborn with Erb palsy. The root and suck reflex are not affected. A grasp reflex is present in newborns because the finger and wrist movements remain normal. DIF: Cognitive Level: Analyzing REF: MCS: 299 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 20. A newborn has been diagnosed with brachial nerve paralysis. The nurse should assist the breastfeeding mother to use which hold or position during feeding? a. Reclining b. The cradle hold c. The football hold d. The cross-over hold ANS: C In brachial nerve paralysis, the affected arm is gently immobilized on the upper abdomen. Tucking the newborn under the arm (football hold) puts less pressure on the newborns affected extremity. The other positions place the newborns body next to the mothers and can cause pressure on the affected arm. DIF: Cognitive Level: Applying REF: MCS: 299 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 21. The parents of an infant with a cleft palate ask the nurse, What follow-up care will our infant need after the repair? Which is aenreascpcounraset by the nurse? a. Your infant will not need any subsequent follow-up care. b. Your infant will only need to be evaluated by an audiologist. c. Your infant will only need follow-up with a speech pathologist. d. Your infant will need follow-up with audiologists and orthodontists. ANS: D A cleft palate means that audiologists will evaluate the childs hearing throughout early childhood and work closely with otolaryngologists to determine if pressure-equalizing (PE) tubes are needed. An infant with a cleft palate will also go through multiple phases of orthodontic intervention to align the teeth and the maxillary arches. Follow-up will be needed as the child grows. Following up with only an audiologist or only a speech pathologist would not be adequate. DIF: Cognitive Level: Applying REF: MCS: 305 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. The nurse is caring for earcahiclldefatftp alate repair who is on a clear liquid diet. Which feeding device should the nurse use to deliver the clear liquid diet? a. Straw b. Spoon c. Sippy cup d. Open cup ANS: D Acceptable feeding idceevs after a cleft pa late repair include open cup for liquids, but rigid utensils such as spoons, straws, and hard-tipped sippy cups should be avoided to prevent accidental injury to the repair. DIF: Cognitive Level: Applying REF: MCS: 307 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Safe and Effective Care Environment 23. A mother has just given birth to a newborn with a cleft lip. Sensing that something is wrong, she starts to cry and asks the nurse, What is wrong with my baby? What is thaeppmropriate nursing action? a. Encourage the mother to express her feelings. b. Explain in simple language that the baby has a cleft lip. c. Provide emotional support until the practitioner can talk to the mother. d. Tell the mother a pediatrician will talk to her as soon as the baby is examined. ANS: B It is best to explain in simple terms the nature of the defect and to reinforce and help aclrify information given by the practitioner before the newborn is shown to the parents. Parents may not be ready to talk about their feelings during the first few days after birth. The nurse should provide information about the childs condition while waiting for the practitioner to speak with the family after the examination. The mother needs simple explanations of her childs condition during this period of waiting. DIF: Cognitive Level: Applying REF: MCS: 303 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 24. An infant requires surgery froepr air of a cleft lip. An important priority of the oppre rative nursing care is which? a. Initiating discharge teaching b. Performing baseline physical and behavioral assessment c. Observing for allergic reactions to preoperative antibiotics d. Determining whether this defect exists in other family members ANS: B It is essential to assess the infant before surgery to obtain a baseline. Postoperative changes can be identified and a determination can be made regarding pain or change in status. The parents are not ready for discharge teaching. Their focus is on the congenital defect and surgery. Although a reibmiloittye,poss allergic reactions urarely occ r on the first dose. Determining whether this defect exists in other family members is an important part of the thoirsy but is not a priority before surgery. DIF: Cognitive Level: Analyzing REF: MCS: 305 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. The nurse is caring for an infant with hemolytic disease. Which medication should the nurse anticipate to be prescribed to decrease the bilirubin level? a. Phenytoin (Dilantin) b. Valproic acid (Depakene) c. Carbamazepine (Tegretol) d. Phenobarbital (Phenobarbital) ANS: D Phenobarbital is used to decrease the bilirubin level in a newborn with hemolytic disease. Phenobarbital promotes (1) hepatic glucuronyl transferase synthesis, which increases bilirubin conjugation and hepatic clearance of the pigment in bile, and (2) protein synthesis, which may increase albumin for moreinbbiliinrduibng sites. Dilantin, Depakene, andoTleagret re antiseizure medications and do not lower bilirubin levels. DIF: Cognitive Level: Analyzing REF: MCS: 318 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 26. A 4-month-old infant is discharged home after surgery for the repair of a fctlelip. What should instructions to the parents include? a. Provide crib toys for distraction. b. Breast- or bottle-feeding can begin immediately. c. Give pain medication to the infant to minimize crying. d. Leave the infant in the crib at all times to prevent suture strain. ANS: C Pain medication and comfort measures are used to minimize infant crying. Interventions are implemented to minimize stress on the suture line. Although crib toys are important, the child should not be left in the crib for prolonged periods. Feeding begins with alternative feeding devices. Sucking puts stress on the suture line in the immediate postoperative period. The infant should not be left in the crib but should be removed for appropriate holding and stimulation. DIF: Cognitive Level: Understanding REF: MCS: 309 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is teaching a new nurse about types of physical injuries that can occur at birth. Which soft tissue injuries should the nurse include in the teaching? (Select all that apply.) a. Petechiae b. Retinal hemorrhage c. Facial paralysis d. Cephalhematoma e. Subdural hematoma f. Subconjunctival hemorrhage ANS: A, B, F Soft tissue injuries that can occur at birth include petechiae, retinal hemorrhage, and subconjunctival hemorrhage. Facial paralysis and cephalhematoma are head injuries that occur at birth, and a subdural hematoma is considered a neurologic injury related to the birthing process. DIF: Cognitive Level: Applying REF: MCS: 294 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 2In. tWeghricyh interventions should the nurse implement for a newborn with a subgaleal hemorrhage? (Select all that apply.) a. Monitor bilirubin levels. b. Monitor hematocrit levels. c. Prepare the newborn for skull radiography. d. Monitor the newborns level of consciousness. e. Place a warm compress on the affected area. ANS: A, B, D An increase in serum bilirubin levels may occur as a result of tdhegrading r ed blood cells within the hematoma. Monitoring the newborn for changes in level of consciousness and a decrease in the hematocrit are keys to early recognition and management. Computed tomography or magnetic resonance imaging, not skull radiography, is useful in confirming the diagnosis. A warm compress would be contraindicated because it may dilate blood vessels and increase bleeding. DIF: Cognitive Level: Applying REF: MCS: 296 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. Which birth injuries should the nurse assess for if an infant was born with the use of a vacuum extractor? (Select all that apply.) a. Torticollis b. Brachial palsy c. Fractured clavicle d. Cephalhematoma e. Subgaleal hemorrhage ANS: B, D, E Brachia palsy, cephalhematoma, and subgaleal hemorrhage are birth injuries associated with vacuum-assisted extraction. Fractured clavicles are injuries associated with infants who are large for gestational age or weigh more than 4000 g. Torticollis is a condition that occurs from a brachial plexus injury. DIF: Cognitive Level: Understanding REF: MCS: 305 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. An infant with an isolated ecflt lip is being bottle f ed. Which actions should the nurse plan to implement to assist with the efeding? (Sleltehcatt al apply.) a. Use an NUK nipple. b. Use cheek support. c. Enlarge the nipple opening. d. Position the infant upright. e. Thicken the formula with rice cereal. ANS: A, B, D A bfeodttilne-fant with an isolated cleft lip should be fed with cheek support (squeezing the cheeks together toedaescerthe width of the cleft), which may help the infant achieve an adequate anterior lip seal during feeding. Systems that have a wider base, such as an NUK (orthodontic) nipple or a Playtex nurser, allow the infant withfat lcilpeto feed more successfully. The infant should be positioned upright with the head supported. This position helps gravity to direct the flow of liquid so that it is aswllowed ra r tthhean e ntering ointhe anlas cavity. Enlarging the nipple opening would allow too much milk too fast for an infant with a cleft palate. Thickening the formula with rice cereal is done for ainnfts with ga stroesophageal reflux, not cleft lip. DIF: Cognitive Level: Applying REF: MCS: 305 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5. The nurse suspects a newborn has a fractured clavicle. What are signs of a fractured clavicle? (Select all that apply.) a. An asymmetric Moro reflex b. Limited use of the affected arm c. Crying when the arm is moved d. Muscles of the hand are paralyzed e. The arm hangs limp alongside the body ANS: A, B, C A newborn with a fractured clavicle may have no signs, but the nurse should suspect a fracture if an infant has limited use of the affected arm, malpositioning of the arm, an asymmetric Moro reflex, or cfoal sw elling or rtennedsse or ecsriwhen t he arm is moved. Paralyzed hand muscles and an arm that hangs limp alongside the body are signs of Erb palsy. DIF: Cognitive Level: Analyzing REF: MCS: 297 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. The nurse is preparing to administer a topical application of 1 ml of nystatin (Mycostatin) to an infant with oral thrush. Which actions should the nurse plan to implement? (Select all that apply.) a. Administer after a feeding. b. Use a sponge applicator to swab the oral mucosa and tongue. c. Administer after warming the medication under running warm water. d. If white patches are no longer present, hold the medication. e. Deposit the remainder of the dose in the mouth with a syringe so the infant swallows a small amount. ANS: A, B, E To administer a topical application of nystatin for oral thrush, the medication should be distributed over the surface of the oral mucosa and tongue with an applicator or syringe. The remainder of the dose is deposited in the mouth to be swallowed by the infant to treat any gastrointestinal lesions. The nystatin should be administered after feedings. The medication should not be warmed before administration, and the medication should continue to be administered until discontinued by the health care provider. Chapter 9.The High-Risk Newborn and Family MULTIPLE CHOICE 1. Which refers to an infant whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts? a. Postterm b. Postmature c. Low birth weight d. Small for gestational age ANS: D A small-for-gestational-age, or small-for-date, infant is one whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. A postterm, or postmature, infant is any child born after 42 weeks of gestation, regardless of birth weight. A low-birtwhe-ight infant is a child whose birth weight is less than 2500 g, regardless of gestational age. DIF: Cognitive Level: Understanding REF: MCS: 338 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. A wmoan in pr emature labor delivers an extremely lowbirth-weight (ELBW) infant. Transport to a neonatal intensive care unit is indicated. The nurse explains that which level of service is needed? a. Level I b. Level IA c. Level II d. Level IIIB ANS: D A level IIIB neonatal unit has the capability of providing care for ELBW infants, including high- frequency ventilation and on-site access to medical subspecialties and pediatric surgery. A level I facility manages normal maternal and newborn care. Infants at less than 35 weeks of gestation are stabilized and transported to a facility that can provide appropriate care. A level IA facility does not exist. Level II facilities provide care for infants born at 32 weeks of gestation and weighing more than 1500 g. If the infant is ill, the health problems are expected to resolve rapidly and are not anticipated to require specialty care. DIF: Cognitive Level: Applying REF: MCS: 339 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I3n. tWeghriattyis an essential component in caring for the very low or extremely lowbirth-weight infant? a. Holding the infant to help develop trust b. Using electronic monitoring devices exclusively c. Coordinating care to reduce environmental stress d. Incorporating infant stimulation elements during assessment ANS: C One of the principles of care for high-risk neonates is close observation and assessment with minimum handling. The nurse checks the apical rate against the monitor readings on a regular basis. The infants care is then clustered, and the infant is disturbed as little as possible. Holding an infant to help develop trust is not part of tahsesessment. I n some areas, parents use skin-to- skin care with their infants. Although electronic monitoring devices are used, the nurse must validate the readings with tihnefants da ta. For la n il stress. eonate, excessive stimulation creates DIF: Cognitive Level: Understanding REF: MCS: 339 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. What explains why a neutral thermal environment is essential for a high-risk neonate? a. The neonate produces heat by increasing activity and shivering. b. Metabolism slows dramatically in the neonate experiencing cold stress. c. It permits the neonate to maintain a normal core temperature with minimum oxygen consumption. d. It permits the neonate to maintain a normal core temperature with increased caloric consumption. ANS: C A high-risk neonate is at greater risk for cold stress than a term infant because of the smaller muscle mass and fewer deposits of brown fat for producing heat, lack of insulating subcutaneous fat, and poor reflex control of skin capillaries. By definition, a neutral thermal environment is one that permits the infant to maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. Smaller muscle mass and poor reflex control of skin capillaries decrease the ability of a high-risk neonate to compensate for an environment that is not thermoneutral. Metabolism increases in an infant experiencing cold stress, creating a compensatory increase in oxygen and caloric consumption. Increased caloric consumption is to be avoided. Neonates need available calories for growth. DIF: Cognitive Level: Analyzing REF: MCS: 342 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 5. When caring for a neonate in a radiant warmer, what should tnhuerse be al ert to? a. Exposure to prolonged cold stress b. Need for Plexiglas shields to protect the infant c. Transepidermal water loss leading to dehydration d. Increased risk of infection from the open environment ANS: C Radiant warmers result in greater evaporative fluid loss than normal, thus predisposing the infant to dehydration. Plastic wrap can help reduce this loss. Daily fluid requirements are increased to compensate. The radiant warmer protects the infant ofrm cold stress. Plexiglas shields are not used iniraandt mwaers becaus e they block the radiant heat waves. With clean and aseptic technique, there is not a greater risk of infection. DIF: Cognitive Level: Analyzing REF: MCS: 343 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 6. The nurse is caring for a high-risk neonate who has an ubmilical ca theter and is in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action? a. Place socks on the infants feet. b. Elevate the infants feet 15 degrees. c. Wrap the infants feet loosely in a prewarmed blanket. d. Report the findings immediately to the practitioner. ANS: D Blanching of the feet in a neonate with an umbilical catheter is an indication of vasospasm. Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency situation and must be reported immediately. DIF: Cognitive Level: Applying REF: MCS: 344 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. Which statement is true ecronnicng the nutritional needs of preterm infants? a. The secretion of lactase is low. b. Carbohydrates and fats are better tolerated than protein. c. The demand for nutrients is less than in full-term infants. d. Breast milk lacks the proper concentration of nutrients. ANS: A The enzyme lactase is not irleyadav ailable in an infants body until after 34 weeks of gestation. Formulas containing lactose are not wleeralltetdo. Carbohydrates and fats are less well lteorated than protein. Preterntsinrefa quire significantly higher intake of calories and other nutrients than full-term infants. The American Academy doifaPtreics recommends 105 to 130 kcal/kg/day. Breast milk from the nintsfam othernisidcoered the lideenateral nutrition for the infant. Several commercial formulas are designed for preterm infants. DIF: Cognitive Level: Analyzing REF: MCS: 345 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action? a. Let the neonate rest before breastfeeding again. b. Resume gavage feedings until the neonate is asymptomatic. c. Recognize that this may indicate an underlying illness. d. Use a high-flow, pliable nipple because it requires less energy to use. ANS: C Apnea, pallor, and bradycardia may be signs of an underlying illness. The infant should be evaluated to ensure he or she is not developing problems. The infant can rest while waiting for the evaluation. If the child is becoming ill, the capacity to digest enteral feedings may be compromised. The type of nipple that is being used should not produce the signs being observed. DIF: Cognitive Level: Applying REF: MCS: 347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 9. A preterm infant who is being fed commercial formula by gavage has had an increase in gastric residuals, abdominal distention, and apneic episodes. Which is the most appropriate nursing action? a. Notify the practitioner. b. Reduce the amount fed by gavage. c. Feed human milk by gavage. d. Feed only a glucose solution until the infant stabilizes. ANS: A These are signs that may indicate early necrotizing enterocolitis. The practitioner is notified for further evaluation. Enteral feedings are usually stopped until the cause of increased residuals is identified. DIF: Cognitive Level: Applying REF: MCS: 347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 10. A mother planned to breastfeed her infant before giving birth at 33 weeks of gestation. The infant is stable and receiving oxygen. What is the most appropriate nursing action related to this? a. Assist the mother in expressing breast milk. b. Assess the infants readiness to breastfeed. c. Explain to the mother that the infant is too small to receive breast milk. d. Reassure the mother that infant formula is a good alternative to breastfeeding. ANS: B Research confirms that human milk is the best source of nutrition for term and preterm infants. Preterm infants should be breastfed as soon as they have adequate sucking and lsowwailng reflexes and no other complications such as respiratory complications or concurrent lilnesses. If the infant has adequate sucking and swallowing, the infant should breastfeed for some of the feedings. The mother can express milk to be used in her absence. DIF: Cognitive Level: Applying REF: MCS: 348 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 11. A preterm neonate has begun breastfeeding, but the infant tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention? a. Encourage the mother to breastfeed. b. Resume orogastric feedings of formula. c. Try nipple feeding the preterm infant formula. d. Feed the remainder of breast milk by the orogastric route. ANS: D If a preterm infant rties easily o r has weak sucking when breastfeeding is initiated, the nurse should feed the additional breast milk by the enteral route. The nurse supports the mother in the attempts to breastfeed and ensures that the infant eisceriving ade quate nutrition. Breast milk should be used as long as the mother can supply it. DIF: Cognitive Level: Applying REF: MCS: 350 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. A preterm infant is being fed by gavage. What is an important consideration for this infant? a. Warm the feeding to body temperature before feeding. b. Feed the infant in an isolette to minimize handling. c. Provide a pacifier for nonnutritive sucking during bolus feeding. d. Do not allow the infant to have increased stress by becoming hungry. ANS: C Nonnutritive sucking during feedings will help the infant associate sucking with food. This can minimize feeding resistance and aversion. Warming the feeding to body temperature is not necessary. The food can be at room temperature. iIbf lpeoss , the infant should be held in a feeding position. The infant should be allowed to become hungry so that the food and nonnutritive sucking are associated with satisfying the hunger. DIF: Cognitive Level: Applying REF: MCS: 347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13. Which is an important nursing action related to the use of tape or adhesives on premature neonates? a. Avoid using tape and adhesives until skin is more mature. b. Remove adhesives with water, mineral oil, or petrolatum. c. Use scissors carefully to remove tape instead of pulling off the tape. d. Use solvents to remove tape and adhesives instead of pulling on the skin. ANS: B Warm water, mineral oil, or rpoeltatum can f acilitate the removal of adhesive. In a premature neonate, often it is impossible to avoid using adhesives and tape. The smallest amount of adhesive necessary should be used. Scissors should not be used to remove dressings or tape from very small and mimature infants because it is easy to snip of f tiny extremities or nickelloyos attached skin. Solvents should be avoided because they tend to dry and burn the delicate skin. DIF: Cognitive Level: Applying REF: MCS: 351 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 14. The nurse is caring for a 3-week-old boy born at 29 weeks of gestation. While taking vital signs and changing his diaper after stooling, the nurse observes his color is pink but slightly mottled, his arms and legs are limp and extended, he has the hiccups, his respirations are deep and rapid, and his heart rate is regular and rapid. The nurse should recognize these behaviors as signs of what? a. Stress b. Subtle seizures c. Preterm behaviors d. Onset of respiratory distress ANS: A These are signs of stress or ifgatue in a newborn. Neonatal seizures usually have some type of repetitive movement, from twitching to rhythmic jerking movements. The behavior of a preterm infant maynbaectiive and l istless. Respiratory distress is exhibited by retractions and nasal flaring. DIF: Cognitive Level: Analyzing REF: MCS: 354 TOP: Nursing Process: Assessment :MCSC ielnt Needs: Physiological Integrity 15. The nurse knows that during deep sleep the neonate should not be disturbed if possible. Characteristics of deep sleep include what? a. Regular breathing b. Occasional smiling c. Rapid eye movements d. Apneic pauses of less than 20 seconds ANS: A Regular breathing is characteristic of deep sleep. During active sleep, irregular breathing may be present. Occasional smiling, rapid eye movements, and apneic pauses of less than 20 seconds are characteristic of active sleep. DIF: Cognitive Level: Understanding REF: MCS: 355 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 16. The nurse is providing care to a preterm infant. Which characteristic of daily care should be considered supportive? a. Coordinated with parental visiting times b. Given on a fixed schedule to ensure needs are met c. Provided when infants heart rate is at its lowest level d. Directed toward development of sleep organization ANS: D Developmentally supportive care uses both behavioral and physiologic information as the basis of caregiving. A focus in preterm infants is to be alert for infant behavioral states and intervene during alert times. The parents should be taught how to recognize the infants behavioral states. Infants sleep for approximately 1 1/2 hours. The parents can provide care when the infant is awake. Care should not be delivered on a fixed schedule. It should always be responsive to the infants cues. The heart rate is at its lowest when the infant is in a sleep period. The infant should not be disturbed during this time if possible. DIF: Cognitive Level: Applying REF: MCS: 355 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 17. What can stroking infants who are physiologically unstable result in? a. Fewer sleep periods b. Increased weight gain c. Shortened hospital stay d. Decreased oxygen saturation ANS: D Tactile interventions can have both positive and negative effects on neonates. For physiologically unstable infants and those who are disturbed during sleep, outcomes such as gasping, grunting, decreased oxygen saturation, apnea, and bradycardia have been observed. Fewer sleep periods are not associated with tactile stimulation inoplhoygsicially un stable infants. Increased weight gain and shortened ahlostpit ays are positive outcomes that are observed when tactile stimulation is done at developmentally supportive times. DIF: Cognitive Level: Applying REF: MCS: 356 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. In about 1 week, a stable preterm infant will be discharged. The nurse should teach the parents to place the infant in which position for sleep? a. Prone b. Supine c. Position of comfort d. Abdomen with head elevated ANS: B The American Academy of Pediatrics recommends that healthy infants be placedeteopsiln a nonprone position. The prone position is associated with sudden infant death syndrome but can be used for supervised play. DIF: Cognitive Level: Applying REF: MCS: 357 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is planning care for a family expecting their newborn infant to die because of an incurable birth defect. What should the nurses interventions be based on? a. Tangible remembrances of the infant (e.g., lock of hair, picture) prolong grief. b. Photographs of infants should not be taken after death. c. Funerals are not recommended because the mother is still recovering from childbirth. d. The parents should be given the opportunity to parent the infant, including seeing, holding, touching, or talking to the infant in private. ANS: D Providing care for the neonate is an important step in the grieving process. It gives the parents a tangible person for whom to grieve, which is a key component of the grieving process. Tangible remembrances and photographs can make the infant seem more real to the parents. Many neonatal intensive care units make bereavement meory paets,cwk hich may include a lock of hair, handprints, footprints, a bedside name card, and other individualized objects. Families need to be informed of their options. The ritual of a funeral provides an opportunity for the parents to be supported by relatives and friends. DIF: Cognitive Level: Applying REF: MCS: 360 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 20. The nurse has been caring for an infant who has just died. The parents are present but appear to be afraid to hold the dead infant. What is the most appropriate nursing intervention? a. Tell them there is nothing to fear. b. Insist that they hold the infant one last time. c. Respect their wishes and release the body to the morgue. d. Keep the infants body available for a few hours in case they change their minds. ANS: D When the parents are hesitant about holding and touching their infant, the nurse should wrap the infant in blankets and keep the infants body on the unit for a few hours. Many parents change their minds taefr the cinkitoiafl sho the infants death. This will provide the parents time to see and hold their infant if they desire. Telling the parents there is nothing to fear minimizes the parents feelings. The nurse should allow the family to parent their child as they wish in death, as in life. DIF: Cognitive Level: Applying REF: MCS: 363 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 21. The parents of an infant who has just died decide they want to hold the infant after their infant has gone to the morgue. What is the most appropriate nursing intervention at this time? a. Explain gently that this is no longer possible. b. Encourage the parents to accept the loss of their infant. c. Offer to take a photograph of their infant because they cannot hold the infant. d. Have the infant brought back to the unit, wrapped in a blanket, and rewarmed in a radiant warmer. ANS: D The parents should be allowed to hold their infant in the hospital setting. The infants body should be retrieved and arerwmed in a diraant warmer. The nurse should provide a private place where the parents can hold their child for a final time. If possible, to facilitate the parents grieving, the nurse should bring the infant back to the unit. A photograph is an excellent idea, but it does not replace the parents need to hold the child. DIF: Cognitive Level: Applying REF: MCS: 363 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 22. Which statement best describes the characteristics of apnretste?rm inf a. Thermoregulation is well established. b. Extremities remain in attitude of flexion. c. Sucking reflex is absent, weak, or ineffectual. d. The head is proportionately small in relation to the body. ANS: C Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. Thermoregulation is poorly developed, and a preterm infant needs to be in a neutral thermal environment. A preterm infant may be listless and inactive compared with the overall attitude of flexion and activity of a full-term nint.faA ptrerm einf ants hdea body. DIF: Cognitive Level: Understanding REF: MCS: 365 is proportionately larger than the TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 23. Which is a characteristic of postmature infants? a. Abundant lanugo b. Lack of scalp hair c. Plump appearance d. Parchment-like skin ANS: D In postterm infants, the skin is often cracked, parchment-like, and desquamating. Lanugo is usually absent. Scalp hair is usually abundant. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance. DIF: Cognitive Level: Understanding REF: MCS: 365 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 24. Which is a central factor responsible for respiratory distress syndrome in a newborn? a. Absence of alveoli b. Immature bronchioles c. Overdeveloped alveoli d. Deficient surfactant production ANS: D The successful adaptation toaeuxtterrine breathing requires numerous factors, w hichmmost ter infants successfully accomplish. Preterm nintsfaw ith preirsatory di stress are not able touasdt.j The most likely central cause is the abnormal development of the surfactant system. The number and state of development of the alveoli are not central factors in respiratory distress syndrome. The instability of the alveoli related to the lack of surfactant is tchaeusative issue. T he bronchioles are sufficiently developed in newborns. DIF: Cognitive Level: Understanding REF: MCS: 368 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Physiological Integrity 25. A preterm infant of 33 weeks of gestation is admitted to the neonatal intensive care unit. Approximately 2 hours after birth, the neonate begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. What should the nurse recognize? a. This is a normal finding. b. Further evaluation is needed. c. Improvement should occur within 24 hours. d. This is not significant unless cyanosis is present. ANS: B These are signs of respiratory distress syndrome and require further evaluation. There is no way to predict the infants clinical course based on the available data. Cyanosis may be present, but these are significant findings indicative of respiratory distress even without cyanosis. DIF: Cognitive Level: Analyzing REF: pp. 375-376 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 26. The nurse is caring for a preterm neonate who requires mechanical ventilation for treatment of respiratory distress syndrome. Because of the mechanical ventilation, the nurse should recognize an increased risk of what? a. Pneumothorax b. Transient tachypnea c. Meconium aspiration d. Retractions and nasal flaring ANS: A Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Tachypnea may be an indication of a pneumothorax, but it should not be transient. Meconium aspiration is not associated with mechanical ventilation. Retractions and nasal flaring are indications of the use of accessory muscles when the infant cannot obtain sufficient oxygen. The use of mechanical ventilation bypasses the infants need to use these muscles. DIF: Cognitive Level: Understanding REF: MCS: 375 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. What are possible premature infant complications from oxygen therapy and mechanical ventilation? a. Bronchopulmonary dysplasia and retinopathy of prematurity b. Anemia and necrotizing enterocolitis c. Cerebral palsy and persistent patent ductus arteriosus d. Congestive heart failure and cerebral edema ANS: A Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by mechanical ventilation ecrates an increase in the number of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Oxygen therapy puts the infant at risk for retinopathy of prematurity. Anemia, necrotizing enterocolitis, cerebral palsy, persistent patent ductus, congestive heart failure, and cerebral edema are not primarily caused by oxygenrtahpey and mechanical ventilation. DIF: Cognitive Level: Analyzing REF: MCS: 381 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 28. A preterm infant with rpesiratory di stress syndrome is receiving inhaled nitric oxide )(.NO What is the reason for administering the inhaleden?itric oxid a. To mature the lungs b. To deliver a level of oxygen that is safe c. To increase the removal of pulmonary debris such as meconium d. To reduce pulmonary vasoconstriction and pulmonary hypertension ANS: D NO is used for infants with conditions such as meconium aspiration syndrome, pneumonia, sepsis, and congenital diaphragmatic hernia. Most infants with these disorders do have mature lungs. NO is not oxygen. Inhaled NO is beneficial for infants with meconium aspiration syndrome, but it does not work by removing debris. Inhaled NO is a significant treatment for infants with persistent pulmonary hypertension, pulmonary vasoconstriction, and subsequent acidosis and severe hypoxia. When inhaled into the lungs, it causes smooth muscle relaxation and reduction of pulmonary vasoconstriction and subsequent pulmonary hypertension. DIF: Cognitive Level: Understanding REF: MCS: 375 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 29. The nurse is caring for a neonate with respiratory distress syndrome. The infant has an endotracheal tube. What should nursing considerations related to suctioning include? a. Suctioning should not be carried out routinely. b. The infant should be in the Trendelenburg position for suctioning. c. Routine suctioning, usually every 15 minutes, is necessary. d. Frequent suctioning is necessary to maintain the patency of the bronchi. ANS: A Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia, and increased intracranial pressure (ICP). It should never be carried out routinely. The Trendelenburg position should be avoided because it can contribute to increased ICP and reduced lung capacity from gravity pushing the organs against the diaphragm. DIF: Cognitive Level: Applying REF: MCS: 376 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 30. What signs should the nurse expect when a pneumothorax occurs in an infant on mechanical ventilation? a. Tachycardia b. Clear, distinct heart tones c. Widened pulse pressure d. Abrupt duskiness or cyanosis ANS: D The early signs of a pneumothorax in an infant on mechanical ventilations include the uabprt onset of duskiness or cyanosis. Tachypnea is the presenting sign. Usually the heart rate is decreased. The heart sounds usually become muffled, diminished, or shifted. The pulse pressure decreases in pneumothorax. DIF: Cognitive Level: Understanding REF: MCS: 379 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 31. What is most descriptive of the signs observed in neonatal sepsis? a. Seizures b. Sudden hyperthermia c. Decreased urinary output d. Subtle, vague, and nonspecific physical signs ANS: D The signs of neonatal sepsis are usually characterized by the infant generally not doing well. Poor temperature control, usually with hypothermia, lethargy, poor feeding, pallor, cyanosis or mottling, and jaundice, may be evident. Seizures are not a manifestation of sepsis. Severe neurologic sequelae may occur in eloigwhbtiirnthfa-wnts w ith psesis. H yperthermia is rare in neonatal sepsis. Urinary output is not affected by sepsis. DIF: Cognitive Level: Understanding REF: MCS: 384 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 32. What is the most common cause of iatrogenic anemia in preterm infants? a. Frequent blood sampling b. Respiratory distress syndrome c. Meconium aspiration syndrome d. Persistent pulmonary hypertension ANS: A The most common cause of anemia in preterm infants is frequent blood-sample withdrawal and inadequate erythropoiesis in acutely ill infants. Microsamples should be used for blood tests, and the amount of blood drawn should be monitored. Respiratory distress syndrome, meconium aspiration syndrome, and persistent pulmonary hypertension are not causes of anemia. They may require frequent blood sampling, which contributes to the problem of decreased erythropoiesis and anemia. DIF: Cognitive Level: Understanding REF: MCS: 388 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 33. A newborn is diagnosed with retinopathy of prematurity. What should the nurse know about this condition? a. Blindness cannot be prevented. b. No treatment is currently available. c. Cryotherapy and laser therapy are effective treatments. d. Long-term administration of oxygen will be necessary. ANS: C Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular proliferation process that causes the retinal damage. Blindness can be prevented with early recognition and treatment. Long-term administration of oxygen is one of the causes. Oxygen should be used judiciously. DIF: Cognitive Level: Understanding REF: MCS: 389 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 34. What is a priority of care for an infant with an intraventricular hemorrhage? a. Avoid use of analgesia. b. Keep the infants head to the right side. c. Minimize interventions that cause crying. d. Encourage the staff and parents to hold the infant. ANS: C The priority goal is to decrease intracranial pressure (ICP). Alolwing the infant to cry will cause an increase in pressure. Analgesia is used as necessary to maintain the child pain free. This reduces ICP. The infant should be positioned with the body and head in the midline position. Turning the childs head to the right side can cause cerebral venous congestion and increased ICP. The child should have minimum stimulation to avoid increases in ICP. DIF: Cognitive Level: Applying REF: MCS: 392 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 35. What is a characteristic of most neonatal seizures? a. Clonic b. Generalized c. Well organized d. Subtle and barely discernible ANS: D Seizures in newborns may be subtle and barely discernible or grossly apparent. Most neonatal seizures are subcortical and do not have the etiologic or prognostic significance of seizures in older children. Clonic seizures are slow, rhythmic jerking movements. Generalized seizures are bilateral jerks of the upper and lower limbs rtheaat a socsiated w ith cetlreoencephalographic discharges. Neonatal seizures are not well organized. DIF: Cognitive Level: Understanding REF: MCS: 393 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 36. What should the nurse anticipate in an infant who was exposed to cocaine during pregnancy? a. Seizures b. Hyperglycemia c. Large for gestational age d. Hypertonia and jitteriness ANS: D The nurse shouldcainptaite neurobehavioral de pression or excitability and implement care directed at the infants manifestations. Few or no neurologic sequelae appear in infants born to mothers who used cocaine during pregnancy. The infant is usually a poor feeder, so hypoglycemia should be more likely than hyperglycemia. The infant usually has intrauterine growth restriction. DIF: Cognitive Level: Understanding REF: MCS: 399 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Physiological Integrity 37. What does the nursing care for infants with fetal alcohol syndrome (FAS) include? a. Nutritional guidance b. An intensive stimulation program c. Facilitation of improvement in cardiovascular status d. An individualized program based on maternal alcohol consumption ANS: A Infants with FAS have characteristic poor feeding behaviors that persist throughout childhood. The nurse assists in devising strategies to improve nutrition. The infant is protected from overstimulation. FAS does not include cardiovascular problems. The effects of FAS do not depend on the quantity of maternal alcohol consumption. DIF: Cognitive Level: Applying REF: MCS: 401 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 38. Women who smoke during pregnancy are most likely to have infants who are what? a. Large for gestational age b. Preterm but size appropriate for gestational age c. Growth restricted in weight only d. Growth restricted in weight, length, and chest and head circumference ANS: D Infants born to mothers who smoke have retardation in all aspects of growth. Infants of mothers with diabetes are large for gestational age. Infants of mothers who smoke are small for gestational age. DIF: Cognitive Level: Understanding REF: MCS: 401 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 39. An infant of a mother with herpes simplex infection has just been born. What should nursing considerations include? a. The infant should be isolated in a nursery. b. No special precautions are necessary. c. The mother and infant should be together in a private room. d. Immediate discharge is indicated to prevent spread of infection. ANS: C The shevriprues ncab e transmitted to the nintfa intrapartum or by direct contact. The mother and infant should room together in a private room to reduce the risk of transmission to other infants and mothers. The infant should be kept with the mother. Placement in the nursery creates the possibility of tramnisssion of the virus. Immediate discharge is not necessary. Good handwashing and a private room will minimize the risk of transmission while allowing the mother and infant to receive postpartum care. DIF: Cognitive Level: Applying REF: MCS: 402 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 40. The nurse is caring for a newborn who was born at 35 weeks of gestation and is considered a late preterm infant. What intervention should be included in the infants care plan? a. Feed the infant dextrose water as the first feeding after 12 hours. b. Promote skin-to-skin care in the immediate postpartum period. c. Avoid administration of the hepatitis B vaccine until after discharge. d. Delay the newborn screening and hearing test until the infant is at 40 weeks corrected age. ANS: B Late preterm infants can usually tolerate skin-to-skin care in the immediate postpartum period, which enhances the bonding process with the parents. A late preterm infant should be given an early feeding of human milk or formula; dextrose water is not required rfothe first feeding. The hepatitis B vaccine and all newborn screening, including the hearing test, should be done before discharge, with no limitation on corrected age. DIF: Cognitive Level: Applying REF: MCS: 337 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 41. The enuisrsc aring for a preterm infant who is receiving caffeine acitetr f or treatment of apnea of prematurity. What signs should indicate caffeine toxicity? a. Bradycardia and hypotension b. Oliguria and sleepiness c. Vomiting and irritability d. Constipation and weight loss ANS: C Caffeine citrate is the medication of choice for the treatment of apnea of prematurity because it has fewer side effects, requires once-daily dosing, has slower elimination, and has a wider therapeutic range than other options. Caffeine toxicity can still occur, so the preterm infant needs to be monitored for signs of toxicity, including vomiting and irritability. Bradycardia, hypotension, oliguria, sleepiness, constipation, and weight loss are not symptoms of toxicity. DIF: Cognitive Level: Analyzing REF: MCS: 368 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 42. The nurse is attending a delivery of a full-term infant with meconium noted in the amniotic fluid. The nurse should understand that what action should be performed in the delivery room? a. The infant will be suctioned with a DeLee trap suctioning device after delivery of the head while the chest is still compressed in the birth canal. b. The infants nose will be suctioned at the delivery of the head; subsequent suctioning of the mouth will occur after completion of the delivery. c. The infant will need to take the first breath after delivery of the head and shoulders and will require tracheal suctioning. d. The infants mouth, nose, and posterior pharynx will be suctioned just after the head is delivered while the chest is still compressed in the birth canal. ANS: D Meconium aspiration syndrome can occur when a fetus is subjected to intrauterine stress that causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid, and the meconium-stained fluid is aspirated with the first breath. To prevent meconium aspiration, the infants mouth, nose, and posterior pharynx should be suctioned just after delivery of the head while the chest is still compressed in the birth canal.eAe tDraepLis no longer used in the delivery room. The infants mouth should be suctioned before the nose and during the delivery, not at the completion of delivery. The infant should not take its first breath without suctioning first and may or may not require tracheal suctioning. DIF: Cognitive Level: Applying REF: MCS: 376 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 43. The nurse is placing an infant in a servocontrol radiant warmer. The nurse should attach the temperature probe to which area of the infants body? a. Scapula b. Sternum c. Abdomen d. Front of the lower leg ANS: C The temperature probe should be placed over a nonbony, well-perfused tissue area such as the abdomen or flank. The scapula, sternum, and front of the lower leg would be a bony area. DIF: Cognitive Level: Applying REF: MCS: 342 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 44. The nurse is preparing to administer a gavage feeding to an infant. The nurse should place the infant in which position for the feeding? a. Supine with the head flat b. Sitting upright in a car seat c. Left side-lying with the head flat d. Prone with the head slightly elevated ANS: D The gavage feeding is best performed when an infant is in a prone or a right side-lying position with the head slightly elevated. Supine and left side-lying with the head flat would not be a recommended position. The infant should not be gavage fed sitting in a car seat. DIF: Cognitive Level: Applying REF: MCS: 347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 45. The neonatal intensive care nurse is planning care for an infant in an incubator. Which interventions should the nurse plan to assure therapeutic visual stimulation for the neonate? a. Use an incubator cover. b. Keep lights bright in the unit. c. Place a cloth over the infants face. d. Leave a visual stimulus at the head of the infants bed. ANS: A Decrease ambient light levels by using an incubator cover and by dimming lights, not keeping them bright. Avoid placing a cloth over the face because lilt cwaius e tactile tiirorinta. Avoid leaving visual stimuli in the beds of infants who cannot escape from it. DIF: Cognitive Level: Applying REF: MCS: 359 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 46. Parents of an infant born at 36 weeks gestation ask the nurse, Will our infant dneaecar s eat trial before being discharged? What is the nurses best rseponse? a. Yes, to see if the car seat is the appropriate size. b. Yes, to determine if blanket rolls will be needed. c. No, your infant was old enough at birth to not need a trial. d. Yes, to monitor for possible apnea and bradycardia while in the seat. ANS: D It is recommended that infants younger than 37 weeks of gestation have a period of observation in an appropriate car seat to monitor for possible apnea and bradycardia. The trial is not done to check the size of the car seat or to determine if blanket rolls will be needed. The infant owrans b at 36 weeks of gestation, so it is recommended to perform a car sear trial. DIF: Cognitive Level: Applying REF: MCS: 362 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 47. The nurse is caring for an infant born at 37 weeks of gestation of a nondiabetic mother just admitted to the neonatal intensive care unit for observation. The nurse notes that which lecithin/sphingomyelin (L/S) ratio ionbetda b efore delivery cinadteis no distress syndrome (RDS)? a. 1.4:1 b. 1.6:1 c. 1.8:1 d. 2:1 ANS: D sk orif respiratory An L/S ratio of 2:1 in nondiabetic mothers indicates virtually no risk of RDS. DIF: Cognitive Level: Analyzing REF: MCS: 372 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 48. The health care provider has prescribed surfactant, beractant (Survanta), to be administered to an infant with respiratory distress syndrome (RDS). The nurse understands that the beractant will be administered by which route? a. Orally b. Intravenously c. Via the ET tube d. Intramuscularly ANS: C Surfactant is administered via the ET tube directly into the infants trachea. DIF: Cognitive Level: Analyzing REF: MCS: 373 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity MULTIPLE RESPONSE 1. The nurse is monitoring an infants temperature to avoid cold stress. The nurse understands that cold stress in the infant can cause which complications? (Select all that apply.) a. Hypoxia b. Hypoglycemia c. Metabolic acidosis d. Respiratory alkalosis e. Increased shivering response ANS: A, B, C Cold stress poses hazards to the neonate through hypoxia, metabolic acidosis, and hypoglycemia. Cold stress does not cause respiratory alkalosis. The infant lacks a shivering response, so it is not a complication of cold stress. DIF: Cognitive Level: Understanding REF: MCS: 342 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 2. The neonatal intensive care nurse is caring for a neonate born at 36 weeks of gestation in an incubator. Which actions should the nurse plan to assure adequate skin care for the neonate? (Select all that apply.) a. Changing any adhesives every 12 hours b. Removing adhesives or skin barriers slowly c. Using an adhesive remover when removing tape d. Applying emollient as needed for dry, flaking skin e. Using cleanser or soaps no more than two or three times a week ANS: B, D, E Skin care for the neonate involves removing adhesive or skin barriers slowly, supporting the skin underneath with one hand and gently peeling away from the skin with the other hand. Emollient should be applied as needed for dry, flaking skin, and cleansers or soaps should be used no more than two or three times a week because they can dry the skin. Adhesive remover, solvents, and bonding agents should be avoided. Adhesives should not be removed for at least 24 hours after application, not 12. DIF: Cognitive Level: Applying REF: MCS: 352 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. The nurse is positioning a preterm neonate. What are therapeutic positions the nurse should implement? (Select all that apply.) a. Elbows extended b. Hands at the side c. Neutral or slightly flexed neck d. Trunk slightly rounded with pelvic tilt e. Hips partially flexed and adducted to near midline ANS: C, D, E Therapeutic positioning of the neonate includes a neutral or slightly flexed neck and the trunk slightly rounded with the pelvis tilted and hips partially flexed and adducted to near midline. The elbows should be flexed, not extended, and the hands should be brought to the face or midline as the position allows, not by the side. DIF: Cognitive Level: Applying REF: MCS: 357 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. The nurse is caring for a neonate on positive-pressure ventilation. The nurse monitors for which complications of positive-pressure tvielantion? (Select all that apply.) a. Pneumothorax b. Pneumomediastinum c. Respiratory distress syndrome d. Meconium aspiration syndrome e. Pulmonary interstitial emphysema ANS: A, B, E Positive-pressure introduced by hmaencical appa ratus increases complications such as pulmonary interstitial emphysema, pneumothorax, and pneumomediastinum. Respiratory distress syndrome and meconium aspiration syndrome are not complications of positive-pressure ventilation. DIF: Cognitive Level: Analyzing REF: MCS: 375 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. The home care nurse is visiting a 6-month-old infant with bronchopulmonary dysplasia (BPD). The nurse assesses the child for which signs of overhydration? (Select all that apply.) a. Edema b. Serum sodium of 140 mEq/L c. Urine specific gravity of 1.008 d. Weight gain of 1 lb in 1 week ANS: A, D Nurses must be alert to signs of overhydration in an infant with BPD such as changes in weight, electrolytes, output measurements, and urine specific gravity and signs of edema. Six-month-old infants gain around 4 to 5 oz a week. One pound in 1 week would indicate fluid retention. Serum sodium of 140 mEq/L and urine specific gravity of 1.008 are normal values and indicate adequate fluid balance. DIF: Cognitive Level: Analyzing REF: MCS: 383 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. The nurse is caring for a neonate with an intraventricular hemorrhage. What interventions should the nurse avoid to prevent any increase in intracranial pressure? (Select all that apply.) a. Keeping the head of the bed flat b. Keeping the environment quiet c. Handling the neonate minimally d. Suctioning the endotracheal tube frequently e. Maintaining the neonates head in a midline position ANS: A, D Some nursing procedures increase intracranial pressure (ICP). For example, blood pressure increases significantly during endotracheal suctioning in preterm infants, and head positioning produces measurable changes in ICP. ICP is highest when infants are in the dependent (flat) position and decreases when the head is in a midline position and elevated 30 degrees. Keeping the environment quiet, handling the neonate minimally, and maintaining the neonates head in a midline position are measures to keep the ICP down. Chapter 10.Health Promotion of the Infant and Family MULTIPLE CHOICE 1. At which age does an infant start to recognize familiar faces and objects, such as his or her own hand? a. 1 month b. 2 months c. 3 months d. 4 months ANS: C The child can recognize familiar objects at approximately age 3 months. rFsotr the fi 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is beginning to develop handeye coordination. DIF: Cognitive Level: Understanding REF: MCS: 422 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner? a. Respond to name. b. React to loud noise with Moro reflex. c. Turn his or her head to side when sound is at ear level. d. Locate sound by turning his or her head in a curving arc. ANS: C At 2 months of age, an infant should turn his or her head to the side when a noise is made at ear level. At birth, infants respond to sound with a startle or Moro reflex. An infant responds to his or her name and locates sounds by turning his or her head in a curving arc at age 6 to 9 months. DIF: Cognitive Level: Understanding REF: MCS: 430 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. Which characteristic best describes the fine motor skills of an infant at age 5 months? a. Neat pincer grasp b. Strong grasp reflex c. Builds a tower of two cubes d. Able to grasp object voluntarily ANS: D At age 5 months, the infant should be able to voluntarily grasp an object. The grasp reflex is present in the first 2 to 3 months of life. Gradually, the reflex becomes voluntary. The neat pincer grasp is not achieved until age 11 months. At age 12 months, an infant will attempt to build a tower of two cubes but will most likely be unsuccessful. DIF: Cognitive Level: Understanding REF: MCS: 430 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. The nurse is checking reflexes on a 7-month-old infant. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended. Which reflex is this? a. Landau b. Parachute c. Body righting d. Labyrinth righting ANS: A When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended; this describes the Landau reflex. It appears at 6 to 8 months and persists until 12 to 24 months. The parachute reflex occurs when the infant is suspended in a horizontal prone position and suddenly thrust downward; the infant extends the hands and fingers forward as if to protect against falling. This appears at age 7 to 9 months and lasts indefinitely. Body righting occurs when turning the hips and shoulders to one side causes all other body parts to follow. It appears at 6 months of age and persists until 24 to 36 months. The labyrinth-righting reflex appears at 2 months and is strongest at 10 months. This reflex involves holding infants in the prone or supine position. They are able to raise their heads. DIF: Cognitive Level: Applying REF: MCS: 433 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. In terms of gross motor development, what should the nurse expect an infant age 5 months to do? a. Sit erect without support. b. Roll from the back to the abdomen. c. Turn from the abdomen to the back. d. Move from a prone to a sitting position. ANS: C Rolling from the abdomen to the back is developmentally appropriate for a 5-month-old infant. The ability to roll from the back to the abdomen is developmentally appropriate for an infant at age 6 months. Sitting erect without support is a developmental milestone usually achieved by 8 months. A 10-month-old infant can usually move from a prone to a sitting position. DIF: Cognitive Level: Understanding REF: MCS: 431 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 6. At which age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 12 months ANS: C Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position. DIF: Cognitive Level: Understanding REF: MCS: 419 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 7. By which age should the nurse expect that an infant will be able to pull to a standing position? a. 5 to 6 months b. 7 to 8 months c. 11 to 12 months d. 14 to 15 months ANS: C Most infants can pull themselves to a standing position eat ag 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs. DIF: Cognitive Level: Understanding REF: MCS: 419 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 8. According to Piaget, a 6-month-old infant should be in which developmental stage? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata ANS: C Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes stage is primarily during the first month of life. The primary circular reaction stage kmsar the replacement of reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata, which occurs at ages 9 to 12 months. This is a transitional stage in which increasing motor skills enable greater exploration of the environment. DIF: Cognitive Level: Understanding REF: MCS: 422 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 9. At which age do most infants begin to fear strangers? a. 2 months b. 4 months c. 6 months d. 12 months ANS: C Between ages 6 and 8 months, fear of strangers and stranger anxiety bmeecoprominent and are related to infants ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning to respond differentially to their mothers. The infant at age 4 months is beginning the process of separation-individuation, which involves recognizing the self and mother as separate beings. eTlwve hmsont is too late; the infant requires referral for evaluation if he or she does not fear strangers by this age. DIF: Cognitive Level: Understanding REF: MCS: 426 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 10. At which age should the nurse expect most infants to begin to say mama and dada with meaning? a. 4 months b. 6 months c. 10 months d. 14 months ANS: C Beginning at about age 10 months, an infant is able to ascribe meaning to the words mama and dada. Four to 6 months is too young for this behavior to develop. At 14 months, the child should be able to attach meaning to these words. By age 1 year, the child can say three to five words with meaning and understand as many as 100 words. DIF: Cognitive Level: Understanding REF: MCS: 426 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 11. At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? a. 1 month b. 2 months c. 3 months d. 4 months ANS: B At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. A 3-month-old infant can recognize familiar faces. At age 4 months, infants can enjoy social interactions. DIF: Cognitive Level: Understanding REF: MCS: 427 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching? a. I can give my baby a ball of yarn to pull apart or different textured fabrics to feel. b. I can use a music box and soft mobiles as appropriate play activities for my baby. c. I should introduce a cup and spoon or pushpull toys for my baby at this age. d. I do not have to worry about appropriate play activities at this age. ANS: B Music boxes and soft mobiles are appropriate play activities for a 2-month-old infant. A ball of yarn to pull apart or different texturedbfraics a re aoprirate for an inf ant at 6 to 9 months. A cup and spoon or pushpull toys are appropriate for an older infant. Infants of all ages should be exposed to appropriate types of stimulation. DIF: Cognitive Level: Analyzing REF: MCS: 428 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 13. What is an appropriate play activity for a 7-month-old icnofuarnatgteo en uvaisl stimulation? a. Playing peek-a-boo b. Playing pat-a-cake c. Imitating animal sounds d. Showing how to clap hands ANS: A Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to clap hands help with kinetic stimulation. Imitating animal sounds helps with auditory stimulation. DIF: Cognitive Level: Applying REF: MCS: 428 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 14. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age? a. Give large pushpull toys for kinetic stimulation. b. Place a cradle gym across the crib to help develop fine motor skills. c. Provide the child with finger paints to enhance fine motor skills. d. Provide a stick horse to develop gross motor coordination. ANS: A A 12-month-old child is able to pull to a stand and walk holding on or independently. Appropriate toys for this age child include large pushpull toys for kinetic stimulation. A cradle gym should not be placed across the crib. Finger paints are appropriate for older children. A 12- month-old child does not have the stability to use a stick horse. DIF: Cognitive Level: Applying REF: MCS: 428 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 15. The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurses best rse?pon a. Allow him to cry for no longer than 15 minutes and then pick him up. b. Babies need comforting and cuddling. Meeting these needs will not spoil him. c. Babies this young cry when they are hungry. Try feeding him when he cries. d. If he isnt soiled or wet, leave him, and hell cry himself to sleep. ANS: B Parents need to learn that a spoiled child is a response to inconsistent discipline and limit setting. It is important to meet the infants developmental needs, including comforting and cuddling. The data suggest that responding to a childs crying canlalyctduea crease the overall icnryg time. Allowing him to cry for no longer than 15 minutes and then picking him up will reinforce prolonged crying. Infants at this age have other needs besides feeding. The parents should be taught to identify their infants cues. Counseling parents on letting the baby cry himself to sleep when not soiled or wet refers to sleep issues, not general infant behavior. DIF: Cognitive Level: Applying REF: MCS: 429 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 16. The enuisrsin terviewing the tfhaer of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up tohtoitu.cH er father says no firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what? a. That the child should be given a time-out b. That the child is old enough to understand the word no c. That the child will learn safety issues better if she is spanked d. That the child should already know that electrical outlets are dangerous ANS: B By age 10 months, children are able to associate meaning with words. The father is using both verbal and physical cues to alert the child to dangerous situations. A time-out is not appropriate. The child is just learning about the environment. Physical discipline should be avoided. The 10- month-old child is too young to understand the purpose of an electrical outlet. DIF: Cognitive Level: Applying REF: MCS: 426 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. At a well-child visit, parents ask the nurse how to know if a daycare facility is a good choice for their infant. Which observation should the nurse stress as especially important to consider when making the selection? a. Developmentally appropriate toys b. Nutritious snacks served to the children c. Handwashing by providers after diaper changes d. Certified caregivers for each of the age groups at the facility ANS: C Health practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when handwashing and other hygienic measures are not consistently used. Developmentally appropriate toys are important, but hygiene and the prevention of disease transmission take precedence. An infant should not have snacks. This is a concern for an older child. Certified caregivers for each age group may be an indicator of a high- quality facility, but parental observation of good hygiene is a better predictor of care. DIF: Cognitive Level: Applying REF: MCS: 435 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 18. A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention? a. Reassure the mother that this is normal at this age. b. Recommend the mother substitute a pacifier for her thumb. c. Assess the infant for other signs of sensory deprivation. d. Suggest the mother breastfeed the infant more often to satisfy her sucking needs. ANS: A Sucking is an infants chief pleasure, and the infant may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. The nurse should explore with the mother her lfienegs about a pacifier versus the thumb. No data support that the child has sensory deprivation. DIF: Cognitive Level: Applying REF: MCS: 436 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. An infant, age 6 months, has six teeth. The nurse should recognize that this is what? a. Normal tooth eruption b. Delayed tooth eruption c. Unusual and dangerous d. Earlier than expected tooth eruption ANS: D Six months is earlier than expected to have six teeth. At age 6 months, most infants have two teeth. Although unusual, having six teeth at 6 months is not dangerous. DIF: Cognitive Level: Understanding REF: MCS: 437 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 20. Which intervention is the most appropriate recommendation for relief of teething pain? a. Rub gums with aspirin to relieve inflammation. b. Apply hydrogen peroxide to gums to relieve irritation. c. Give the infant a frozen teething ring to relieve inflammation. d. Have the infant chew on a warm teething ring to encourage tooth eruption. ANS: C Teething pain is a result of inflammation, and cold is soothing. A frozen teething ring or ice cube wrapped in a washcloth helps relieve the inflammation. Aspirin is contraindicated secondary to the risks of aspiration. Hydrogen peroxide does not have an anti-inflammatory effect. Warmth increases inflammation. DIF: Cognitive Level: Applying REF: MCS: 437 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 21. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her? a. Fluids in addition to breast milk are not needed. b. Water should be given if the infant seems to nurse longer than usual. c. Clear juices are better than water to promote adequate fluid intake. d. Water once or twice a day will make up for losses resulting from environmental temperature. ANS: A Infants who are breastfed or bottle fed do not need additional water during the first 4 months of life. Excessive intake of water can create problems such as water intoxication, hyponatremia, or failure to thrive. Juices provide empty calories for infants. DIF: Cognitive Level: Applying REF: MCS: 438 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. At what age is it safe to give einmfants whol ilk aindstoe f commercial infant formula? a. 6 months b. 9 months c. 12 months d. 18 months ANS: C The American Academy of Pediatrics does not recommend the use of cows milk for children younger than 12 months. At 6 and 9 months, the infant should be receiving breast milk or iron- fortified commercial infant formula. At age 18 months, milk and formula are supplemented with solid foods, water, and some fruit juices. DIF: Cognitive Level: Understanding REF: MCS: 440 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 23. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend? a. Heat only 10 oz or more. b. Do not thaw or heat breast milk in a microwave oven. c. Always leave the bottle top uncovered to allow heat to escape. d. Shake the bottle vigorously for at least 30 seconds after heating. ANS: B Using a microwave oven to thaw or heat breast milk decreases the anti-infective properties of the breast milk, lowers the vitamin C content, and changes the fat content. Breast milk should be thawed overnight in a refrigerator or in a warm water bath. A microwave should not be used. If steam is created, the milk is too hot. The bottle should be inverted several times after defrosting or warming. DIF: Cognitive Level: Applying REF: MCS: 439 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Health Promotion and Maintenance 24. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the babys formula faster. What should the nurse recommend? a. Heat only 8 oz or more. b. Do not heat a plastic bottle in a microwave oven. c. Leave the bottle top uncovered to allow heat to escape. d. Shake the bottle vigorously for at least 30 seconds after heating. ANS: C If a microwave is being used, the bottle should be left uncovered. This will allow heat to escape. No more than 4 oz should be heated at any one time. Bottles can be heated safely in microwave ovens if safety guidelines are followed. The bottle should be inverted 10 times; vigorous shaking is not necessary. DIF: Cognitive Level: Applying REF: MCS: 439 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 25. What is the best age to introduce solid food into an infants diet? a. 2 to 3 months b. 4 to 6 months c. When birth weight has tripled d. When tooth eruption has started ANS: B Physiologically and developmentally, 4- to 6-month-old infants are in a transition period. The extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding. Two to 3 months is too young. The extrusion reflex is strong, and the child will push food out with the tongue. No research indicates that the addition of solid food to a bottle has any benefit. Infant birth weight doubles at 1 year. Solid foods can be started earlier. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability. DIF: Cognitive Level: Understanding REF: MCS: 439 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 26. The parent of 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurses best response? a. The infant needs to begin taking them now. b. Supplements are not needed if you drink fluoridated water. c. The infant may need to begin taking them at age 6 months. d. The infant can have infant cereal mixed with fluoridated water instead of supplements. ANS: C Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 6 months if the child is not drinking adequate amounts of fluoridated water. Supplementation is not recommended before age 6 months regardless of whether the mother drinks fluoridated water. Infant cereal is not recommended at 2 weeks of age. DIF: Cognitive Level: Applying REF: MCS: 440 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 27. An infant, age 5 months, is brought to the clinic by his parents for baawbeyllc-heckup. What is the best advice that the nurse should include at this time about injury prevention? a. Keep buttons, beads, and other small objects out of his reach. b. Do not permit him to chew paint from window ledges because he might absorb too much lead. c. When he learns to roll over, you must supervise him whenever he is on a surface from which he might fall. d. Lock the crib sides securely because he may stand and lean against them and fall out of bed. ANS: A Aspiration of foreign objects is a great srik at this age. Penatsr are instructed to ke epaslml objects out of the infants reach. At this age, the child is not mobile enough to reach window sills. If window sills have cracked or chipped paint, it needs to be removed before he is a toddler. This child should already be rolling over. This information is reinforced but should have been taught earlier. Pulling to a stand occurs between 8 and 12 months of age. DIF: Cognitive Level: Applying REF: MCS: 443 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurses reply should be based on what? a. The child is too young to digest hot dogs. b. The child is too young to eat hot dogs safely. c. Hot dogs must be sliced into sections to prevent aspiration. d. Hot dogs must be cut into small, irregular pieces to prevent aspiration. ANS: D To eat a hot dog safely, the child should be sitting down, and the hot dog should be cut into small, irregular pieces rather than served whole or in slices. The childs digestive system is mature enough to digest hot dogs. Hot dogs are of a consistency, diameter, and shape that may cause complete obstruction of the childs airway if not cut into irregular, small pieces. DIF: Cognitive Level: Applying REF: MCS: 445 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 29. In teaching parents about appropriate pacifier selection, the nurse should recommend which characteristic? a. Easily grasped handle b. Detachable shield for cleaning c. Soft, pliable material d. Ribbon or string to secure to clothing ANS: A A good pacifier should be easily grasped by the infant. One-piece construction is necessary to avoid having the nipple and guard separate, posing a risk for aspiration. The material should be sturdy and flexible. If the pacifier is too pliable, it may be aspirated. No ribbon or string should be attached. This poses additional risks. DIF: Cognitive Level: Applying REF: MCS: 436 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 30. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should enxtphlaatithe safest w ay to put in the car seat is what? a. Front facing in back seat b. Rear facing in back seat c. Front facing in front seat with air bag on passenger side d. Rear facing in front seat if an air bag is on the passenger side ANS: B A rear-facing car seat provides the best protection for an infants disproportionately heavy head and weak neck. The middle of the back seat is the safest position for the child. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat. DIF: Cognitive Level: Applying REF: MCS: 443 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 31. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infants crib. What is the most appropriate response for the nurse to make? a. You should put your baby to sleep 1 hour earlier without the nighttime feeding but with a pacifier for soothing. b. You could place rice cereal in the last bottle feeding of the day to ensure a longer sleep pattern. c. You should have your partner give the last bottle of the day and observe whether your infant stays awake for your partner. d. You could increase daytime feeding intervals to every 4 hours and put your baby in the crib while the baby is still awake. ANS: D Increasing the daytime intervals to 4 hours and placing the baby in the crib while still awake are interventions for nighttime sleeping problems. Putting the baby to bed 1 hour earlier with a pacifier will not stop the need fthoer bedtime bottle; there is no research t raice c ereal in the bottle helps to satisfy the baby longer at night, and switching partners does not guarantee that the baby will go to sleep better. DIF: Cognitive Level: Applying REF: MCS: 441 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is performing an assessment on a 12-month-old infant. Which fine or gross motor developmental skill demonstrates the proximodistal acquisition of skills? a. Standing b. Sitting without assistance c. Fully developed pincer grasp d. Taking a few steps holding onto something ANS: C Acquisition noef fi and gross motor skills occurs in an orderly center-to-periphery (proximodistal) or head-to-toe (cephalocaudal) sequence. A fully developed pincer grasp is an example of the proximodistal development because infants use a palmar graspobrefdeveloping the finer pincer grasp. aSnt ding, sitting without satsasni ce, an d taking a few steps are examples of a cephalocaudal development sequence. DIF: Cognitive Level: Analyzing REF: MCS: 417 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 33. An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age? a. 12 lb, 20 inches b. 14 lb, 21.5 inches c. 16 lb, 23 inches d. 18 lb, 24.5 inches ANS: C Infants gain 680 g (1.5 lb) per month until age 5 months, when the birth weight has at least doubled. Height increases by 2.5 cm (1 inch) per month during the first 6 months. Therefore, at 5 months the infant should weigh 16 lb and be 23 inches in length. DIF: Cognitive Level: Understanding REF: MCS: 413 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 34. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia? a. Maternally derived iron stores are depleted in the first 2 months. b. Fetal hemoglobin results in a shortened survival of red blood cells. c. The production of adult hemoglobin decreases in the first year of life. d. Low levels of fetal hemoglobin depress the production of erythropoietin. ANS: B Fetal hemoglobin results in a shortened survival of red blood cells (RBCs) and thus a decreased number of RBCs. Maternally derived rireosnasto re psernet for the tfi5rst o 6 months results in a shortened survival of CRsBand thus a decreased number of CRsB. H igh levels of fetal hemoglobin depress the production of erythropoietin, a hormone released by the kidney that stimulates RBC production. DIF: Cognitive Level: Applying REF: MCS: 416 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 35. The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if ythme ake which statement? a. Our baby should comprehend the word no. b. Our baby knows the meaning of saying mama. c. Our baby should be able to say three to five words. d. Our baby should begin to combine syllables, such as dada. ANS: D By 6 months, infants imitate sounds; add the consonants t, d, and w; and combine syllables (e.g., dada), but they do not ascribe meaning to the word until 10 to 11 months of age. By 9 to 10 months, they comprehend the meaning of the word no and obey simple commands accompanied by gestures. By age 1 year, they can say three to five words with meaning and may understand as many as 100 words. DIF: Cognitive Level: Applying REF: MCS: 426 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 36. The nurse is performing an eansstessm on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which? a. The infant responds to his own name. b. The infant localizes sounds by turning his head directly to the sound. c. The infant turns his head to the side when sound is made at the level of the ear. d. The infant locates sound by turning his head to the side and then looking up or down. ANS: C At 8 to 12 weeks of age, the infant turns the head dtoe the si when sound is made at the level of the ear. At 16 to 24 weeks, the infant locates sound by turning the head to the side and then looking up or down. At 24 to 32 weeks, infants respond to their own name. At 32 to 40 weeks, the infant localizes sounds by turning the head directly toward the sound. DIF: Cognitive Level: Understanding REF: MCS: 415 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is teaching a group of parents at a community education program about introducing solid foods to their infants. Which recommendations should the nurse include? (Select all that apply.) a. Spoon feeding should be introduced after an entire milk feeding. b. It is best to introduce a wide variety of foods during the first year. c. As solid food consumption increases, the quantity of milk should decrease. d. Introduction of low-calorie milk and food should be done by the end of the first year. e. Introduction of citrus fruits, meats, and eggs should be delayed until after 6 months of age. f. Each new food item should be introduced at 5- to 7-day intervals. ANS: B, C, E, F Teaching related to feeding an infant solid foods should include introducing a wide variety of foods because an infant has not developed a strong food preference as seen with a toddler. As solid food consumption increases, the amount of milk consumed should decrease to less than 1 L/day to prevent overfeeding. Introduction to citrus fruits, meats, and eggs should be delayed until after 6 months of age because of the potential to cause food allergies. New foods should be introduced at 5- to 7-day intervals to evaluate for food allergies. Spoon feedings should be introduced after a small ingestion of milk, not at the end of a milk feeding, to associate the activity with pleasure. In general, low-calorie milk and food should be avoided. DIF: Cognitive Level: Applying REF: MCS: 439 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 2. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching? (Select all that apply.) a. Keep baby powder out of reach. b. Inspect toys for removable parts. c. Allow the infant to take a bottle to bed. d. Teething biscuits can be used for teething discomfort. e. The infant should not be fed hard candy, nuts, or foods with pits. ANS: A, B, E Anticipatory guidance to prevent aspiration for a 4-month-old infant takes into account that the infant will begin to be more active and place objects in the mouth. Toys should be checked for removable parts; baby powder should be kept out of reach; and hard candy, nuts, and foods with pits should be avoided. The infant should not go to bed with a bottle. Teething biscuits should be used with caution because large chunks may be broken off and aspirated. DIF: Cognitive Level: Applying REF: MCS: 443 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 3. The nurse is providing anticipatory guidance to parents of an 8-month-old infant on preventing a drowning injury. Which should the nurse include in the teaching? (Select all that apply.) a. Fence swimming pools. b. Keep bathroom doors open. c. Eliminate unnecessary pools of water. d. Keep one hand on the child while in the tub. e. Supervise the child when near any source of water. ANS: A, C, D, E Anticipatory guidance to prevent drowning for an 8-month-old infant takes into account that the child will begin to crawl, cruise around furniture, walk, and climb. Fences should be placed around swimming pools, unnecessary pools of water should be eliminated, one hand should be kept on the child when bathing, and the child should be supervised when near any source of water. The bathroom doors should be kept closed. DIF: Cognitive Level: Applying REF: MCS: 443 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 4. The nurse is providing anticipatory guidance to the parents of a 1-month-old infant on preventing a suffocation injury. Which should the nurse include in the teaching? (Select all that apply.) a. Do not place pillows in the infants crib. b. Crib slats should be 4 inches or less apart. c. Keep all plastic bags stored out of the infants reach. d. Plastic over the mattress is acceptable if it is covered with a sheet. e. A pacifier should not be tied on a string around the infants neck. ANS: A, C, E Anticipatory guidance for a 1-month-old infant to prevent a suffocation injury takes into account that the infant will have increased eyehand coordination and arvolunt y grasp reflex as well as a crawling reflex that may propel the ainnft forward or backward. Pillows should not be placed in the infants crib, plastic bags should be kept out of reach, and a pacifier should not be tied on a string around the neck. Crib slats should be 2.4 inches apart (4 inches is too wide), and the mattress should not be covered with plastic even if a sheet is used to cover it. DIF: Cognitive Level: Applying REF: MCS: 443 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 5. The nurse is providing anticipatory guidance to parents of a 6-month-old on preventing an accidental poisoning injury. Which should the nurse include in the teaching? (Select all that apply.) a. Place plants on the floor. b. Place medications in a cupboard. c. Discard used containers of poisonous substances. d. Keep cosmetic and personal products out of the childs reach. e. Make sure that paint for furniture or toys does not contain lead. ANS: C, D, E Anticipatory guidance for a 7-month-old infant to prevent a suffocation injury takes into account that the infant will become more active and eventually crawl, cruise, and walk. Used containers of poisonous substances should be discarded, cosmetic and personal products should be kept out of the childs reach, and paint for furniture or toys should be lead free. Plants should be hung out of reach or placed on a high shelf. Medications should be locked, not just placed in a cupboard. DIF: Cognitive Level: Applying REF: MCS: 443 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 6. The clinic nurse is assessing a 6-month-old infant during a well-child appointment. The nurse should use which approaches to alleviate the infants stranger anxiety? (Select all that apply.) a. Talk in a loud voice. b. Meet the infant at eye level. c. Avoid sudden intrusive gestures. d. Maintain a safe distance initially. e. Pick up the infant and hold him or her closely. ANS: B, C, D The best approaches for the nurse to alleviate the infants stranger anxiety are to talk smoeftelty; the infant at eye level (to appear smaller); maintain a safe distance from the infant; and avoid sudden, intrusive gestures, such as holding out the arms and smiling broadly. Talking in a loud voice and picking the infant up would increase the infants anxiety. DIF: Cognitive Level: Applying REF: MCS: 426 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is evaluating a 7-month-old infants cognitive development. Which behaviors should the nurse anticipate evaluating? (Select all that apply.) a. Imitates sounds b. Shows interest in a mirror image c. Comprehends simple commands d. Actively searches for a hidden object e. Attracts attention by methods other than crying ANS: A, B, E A 7-month-old infant is in the secondary circular reactions (48 amgoenths) st of cognitive development. Behaviors in this stage include imitating sounds, showing interest in a mirror image, and attracting attention by methods other than crying. Comprehending simple commands and actively searching for a hidden object are behaviors seen in the coordination of secondary schemas (912 months). DIF: Cognitive Level: Applying REF: MCS: 431 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is npnlaing play activities for a 2-month-old hospitalized infant to stimulate the auditory sense. Which activities should the nurse implement? (lSthelaetct al apply.) a. Talk to the infant. b. Play a music box. c. Place a squeaky doll in the crib. d. Give the infant a small-handled clear rattle. ANS: A, B, D Auditory stimulation appropriate for a 2-month-old infant includes talking to the infant, playing a music box, and giving the infant a small-handled clear rattle. Placing a squeaky doll in the crib is appropriate for an infant 6 months of age or older. Chapter 11.Health Problems of the Infant MULTIPLE CHOICE 1. Rickets is caused by a deficiency in what? a. Vitamin A b. Vitamin C c. Folic acid and iron d. Vitamin D and calcium ANS: D Fat-soluble vitamin D iaunmd calc are necessary intadequa e amounts to prevent rickets. No correlation exists between rickets and folic acid, iron, or vitamins A and C. DIF: Cognitive Level: Remembering REF: MCS: 452 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. Which factors will decrease iron absorption and should not be given at the same time as an iron supplement? a. Milk b. Fruit juice c. Multivitamin d. Meat, fish, poultry ANS: A Many foods interfere with iron absorption and should be avoided when iron is consumed. These foods include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables. Vitamin Ccontaining juices enhance the absorption of iron. Multivitamins may contain iron; no contraindication exists to taking the two together. Meat, fish, and poultry do not affect absorption. DIF: Cognitive Level: Understanding REF: MCS: 454 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 3. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their children. Which is most likely lacking in their particular diet? a. Fat b. Protein c. Vitamins C and A d. Iron and calcium ANS: D Deficiencies can occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets because plant foods such as soy are high in phytates. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available. DIF: Cognitive Level: Applying REF: MCS: 454 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological Integrity 4. A 1-year-old child is on a pure vegetarian (vegan) diet. This diet requires supplementation with what? a. Niacin b. Folic acid c. Vitamins D and B12 d. Vitamins C and E ANS: C Pure vegetariang(avne) diets eliminate any food of animal origin, including milk and eggs. These diets require supplementation with many vitamins, especially vitamin B6, vitamin B12, riboflavin, vitamin D, iron, and zinc. Niacin, folic acid, and vitamins C and E are readily obtainable from foods of vegetable origin. DIF: Cognitive Level: Applying REF: MCS: 453 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 5. What is marasmus? a. Deficiency of protein with an adequate supply of calories b. Syndrome that results solely from vitamin deficiencies c. Not confined to geographic areas where food supplies are inadequate d. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites) ANS: C Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic areas were food supplies are inadequate. Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears old, with flabby and wrinkled skin. Marasmus is a deficiency of both protein and calories. DIF: Cognitive Level: Understanding REF: MCS: 456 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much? a. 4 oz/day b. 6 oz/day c. 8 oz/day d. 12 oz/day ANS: A Restrikcet ijnuice inta hildren with dFeTqTuauntil a te weight gain has been achieved with appropriate milk sources; thereafter, give no more than 4 oz/day of juice. DIF: Cognitive Level: Understanding REF: MCS: 465 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 7. An infant has been diagnosed with an allergy to milk. In teaching the parent how to meet the infants nutritional needs, the nurse states that a. Most children will grow out of the allergy. b. All dairy products must be eliminated from the childs diet. c. It is important to have the entire family follow the special diet. d. Antihistamines can be used so the child can have milk products. ANS: A Approximately 80% of children with cows milk allergy develop tolerance by the fifth birthday. The child can have eggs. Any food that has milk as a component or filler is eliminated. These foods include processed meats, salad dressings, soups, and milk chocolate. Having the entire family follow the special diet would provide support for the child, but the nutritional needs of other family members must be addressed. Antihistamines are not used for food allergies. DIF: Cognitive Level: Applying REF: MCS: 460 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I8n. tLegacrittoyse intolerance is diagnosed in an 11-month-old infant. Which should the nurse recommend as a milk substitute? a. Yogurt b. Ice cream c. Fortified cereal d. Cows milkbased formula ANS: A Yogurt contains the inactive lactase enzyme, which is activated by the temperature and pH of the duodenum. This lactase activity substitutes for the lack of endogenous lactase. Ice cream and cows milkbased formula contain lactose, which will probably not be tolerated by the child. Fortified cereal does not have the nutritional equivalents of milk. DIF: Cognitive Level: Applying REF: MCS: 462 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I9n. tWeghricyh term refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation? a. Congenital lactase deficiency b. Primary lactase deficiency c. Secondary lactase deficiency d. Developmental lactase deficiency ANS: D Developmental lactase deficiency refers to the relative lactase deficiency voebdseirn preterm infants of less than 34 weeks of gestation. Congenital lactase deficiency occurs soon after birth after the newborn has consumed lactose-containing milk. Primary lactase deficiency, sometimes referred to as late-onset lactase deficiency, is the most common type of lactose intolerance and is manifested usually after 4 or 5syoefar age. Secondary lactase deficiency may occur secondary to damage of the intestinal lumen, which decreases or destroys the enzyme lactase. DIF: Cognitive Level: Understanding REF: MCS: 462 TOP: Nursing Process: Assessment MSC: Client eNdes: Physiologica l Integrity 10. Which statement best describes colic? a. Periods of abdominal pain resulting in weight loss b. Usually the result of poor or inadequate mothering c. Periods of abdominal pain and crying occurring in infants older than age 6 months d. A paroxysmal abdominal pain or cramping manifested by episodes of loud crying ANS: D Colic is described as paroxysmal abdominal pain or cramping that is manifested by loud crying and drawing up the legs to the abdomen. Weight loss is not part of the icclianl picture. There a re many theories about the cause of colic. Emotional stress or tension between the parent and child is one component. This is not consistent throughout all cases. Colic is most common in infants younger than 3 months of age. DIF: Cognitive Level: Understanding REF: MCS: 470 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. The nptaroef an infant with colic tells sthee, Anur ll this baby does is rsecam a t me; it is a constant worry. tWi ha s the nurses best action? a. Encourage the parent to verbalize feelings. b. Encourage the parent not to worry so much. c. Assess the parent for other signs of inadequate parenting. d. Reassure the parent that colic rarely lasts past age 9 months. ANS: A Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathetic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parents anxiety. The nurse should reassure the parent that he or she is not doing anything wrong. The infant with colic is experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will eventually go away does not help him or her through the current situation. DIF: Cognitive Level: Applying REF: MCS: 479 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 12. What may a icnlica l manifestations of failure to thrive (FTT) in oan1t3h--m old include? a. Irregularity in activities of daily living b. Preferring solid food to milk or formula c. Weight that is at or below the 10th percentile d. Appropriate achievement of developmental landmarks ANS: A One of the calilnmi anifestations of childrenhwFit TT is irregularity or low rhythmicity in activities of daily living. Children with FTT often refuse to switch from liquids to solid foods. Weight below the fifth percentile is indicative of FTT. Developmental delays, including social, motor, adaptive, and language, exist. DIF: Cognitive Level: Understanding REF: MCS: 462 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 13. Which one of the following strategies might be recommended for an infant with failure to thrive (FTT) to increase caloric intake? a. Vary the schedule for routine activities on a daily basis. b. Be persistent through 10 to 15 minutes of food refusal. c. Avoid solids until after the bottle is well accepted. d. Use developmental stimulation by a specialist during feedings. ANS: B Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Children with FTT need a structured routine to help teasblish rhythmicity in their activities of daily living. Many children with FTT are fed exclusively from a bottle. Solids should be fed first. Stimulation is reduced during mealtimes to maintain the focus on eating. DIF: Cognitive Level: Understanding REF: MCS: 465 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 14. The nurse is examining an infant, age 10 months, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with sllaite le sions. What is the most likely cause? a. Impetigo b. Urine and feces c. Candida albicans infection d. Infrequent diapering ANS: C C. albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact with the diaper but sparing the folds are likely to be caused by chemical irritation, especially urine and feces, and may be related to infrequent diapering. DIF: Cognitive Level: Understanding REF: MCS: 466 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 15. A new parent asks the nurse,wHocan diaper r ashebveenptred? What should the nurse recommend? a. Wash the infant with soap before applying a thin layer of oil. b. Clean the infant with soap and water every time diaper is changed. c. Wipe stool from the skin using water and a mild cleanser. d. When changing the diaper, wipe the buttocks with oil and powder the creases. ANS: C Change the diaper as soon as it becomes soiled. Gently wipe stool from the skin with water and mild soap. The skin should be thoroughly dried after washing. Applying oil does not create an effective barrier. Over washing the skin should be avoided, especially with perfumed soaps or commercial wipes, which may be irritating. Baby powder should not be used because of the danger of aspiration. DIF: Cognitive Level: Applying REF: MCS: 467 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I1n6t.eWgrihtayt is most descriptive of atopic dermatitis (AD) (eczema) in an infant? a. Easily cured b. Worse in humid climates c. Associated with hereditary allergies d. Related to upper respiratory tract infections ANS: C AD is a type of pruritic eczema that usually begins during infancy and is associated with allergy with a hereditary tendency. Approximately 50% of children with AD develop asthma. AD can be controlled but not cured. Manifestations of the disease are worse when environmental humidity is lower. AD is not associated with respiratory tract infections. DIF: Cognitive Level: Understanding REF: MCS: 468 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 17. Where do eczematous lesions most commonly occur in an infant? a. Abdomen, cheeks, and scalp b. Buttocks, abdomen, and scalp c. Back and flexor surfaces of the arms and legs d. Cheeks and extensor surfaces of the arms and legs ANS: D The lesions of atopic dermatitis are generalized ianntisn.fT hey are most common on the cheeks, scalp, trunk, and extensor surfaces of the extremities. Tabhdeomen and bu toctks are not common sites of lesions. The back and flexor surfaces are not usually involved. DIF: Cognitive Level: Understanding REF: MCS: 468 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 18. The nurse is discussing the management of atopic dermatitis (eczema) with a parent. What should be included? a. Dress infant warmly to prevent chilling. b. Keep the infants fingernails and toenails cut short and clean. c. Give bubble baths instead of washing lesions with soap. d. Launder clothes in mild detergent; use fabric softener in the rinse. ANS: B The infants nails should be kept short and clean and have no sharp edges. Gloves or cotton socks can be placed over the childs hands and pinned to the shirt sleeves. Heat and humidity increase perspiration, which can exacerbate the eczema. The child should be dressed properly for the climate. Synthetic material (not wool) should be used for the childs clothing during cold months. Baths are given as prescribed with tepid water, and emollients such as Aquaphor, Cetaphil, and Eucerin are applied within 3 minutes. Soap (except as indicated), bubble bath oils, and powders are avoided. Fabric softener should be avoided because of the irritant effects of some of its components. DIF: Cognitive Level: Applying REF: MCS: 469 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 1In9t.eTgrhietyparents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurses response should be based on remembering what? a. This is acceptable to encourage head control and turning over. b. This is acceptable to encourage fine motor development. c. This is unacceptable because of the risk of sudden infant death syndrome (SIDS). d. This is unacceptable because it does not encourage achievement of developmental milestones. ANS: A These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs to reduce the risk of SIDS and then be placed on their abdomens when awake to enhance achievement of milestones such as head control. These position changes encourage gross motor, not fine motor, development. DIF: Cognitive Level: Analyzing REF: MCS: 473 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 20. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been noted of which pediatric issues? a. Sudden infant death syndrome (SIDS) b. Plagiocephaly c. Failure to thrive d. Apnea of infancy ANS: B Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull. If that side becomes misshapen, facial asymmetry may result. SIDS has decreased by more than 40% with the introduction of the Back to Sleep campaign. Apnea of infancy and failure to thrive are unrelated to the Back to Sleep campaign. DIF: Cognitive Level: Understanding REF: MCS: 478 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 21. The nurse is interviewing the parents of a 4-month-old boy brought to the hospital emergency department. The infant is dead, and no attempt at resuscitation is made. The parents state that the baby was found in his crib with a blanket over his head, lying face down in bloody fluid from his nose and mouth. The nurse might initially suspect his death was caused by what? a. Suffocation b. Child abuse c. Infantile apnea d. Sudden infant death syndrome (SIDS) ANS: D The description of how the child was found in the crib is suggestive of SIDS. The nurse is careful to tell the parents that a diagnosis cannot be confirmed until an autopsy is performed. DIF: Cognitive Level: Applying REF: MCS: 473 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)? a. Discourage the parents from making a last visit with the infant. b. Make a follow-up home visit to the parents as soon as possible after the childs death. c. Explain how SIDS could have been predicted and prevented. d. Interview the parents in depth concerning the circumstances surrounding the childs death. ANS: B A competent, qualified professional should visit the family at home as soon as possible after the death. Printed information about SIDS should be provided to the family. Parents should be allowed and encouraged to make a last visit with their child. SIDS cannot always be prevented or predicted, but parents can take steps to reduce the risk (e.g., supine sleeping, removing blankets and pillows from the crib, and not smoking). Discussions about the cause only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. DIF: Cognitive Level: Analyzing REF: MCS: 477 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 23. What is an appropriate action when an infant becomes apneic? a. Shake vigorously. b. Roll the infants head to the side. c. Gently stimulate the trunk by patting or rubbing. d. Hold the infant by the feet upside down with the head supported. ANS: C If an infant is apneic, the infants trunk should be gently stimulated by patting or rubbing. If the infant is prone, turn onto the back. Vigorous shaking, rolling of the head, and hanging the child upside down can cause injury and should not be done. DIF: Cognitive Level: Understanding REF: MCS: 481 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 24. A parent brings a 12-month-old infant into the emergency department and tells the nurse that the infant is allergic to peanuts and was accidentally given a cookie with peanuts in it. The infant is dyspneic, wheezing, and cyanotic. The health care provider has prescribed a dose of epinephrine to be administered. The infant weighs 24 lb. How many milligrams of epinephrine should be administered? a. 0.11 to 0.33 mg b. 0.011 to 0.3 mg c. 1.1 to 3.3 mg d. 11 to 33 mg ANS: B The correct dose of epinephrine to use in the emergency management hoyf laanctaicnarpeaction is 0.001 mg/kg up to a maximum of 0.3 mg, giving a range of 0.011 to 0.3 mg using a weight of 11 kg (24 lb). DIF: Cognitive Level: Applying REF: MCS: 459 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. The nurse is teaching tahpaar2ent wi -month-old infant who has been diagnosed with colic about wtoayrs teaching? elieve colic. Which statement bpyartehnet indicates the need for iaodndailt a. I should let my infant cry for at least 30 minutes before I respond. b. I will swaddle my infant tightly with a soft blanket. c. I should massage my infants abdomen whenever possible. d. I will place my infant in an upright seat after feeding. ANS: A Because the infant has been diagnosed with colic, the parent should respond to the infant immediately or any type of interventions to relieve colic may not be effective. Also, the infant may develop a mistrust of the world if his or her needs are not met. The parent should swaddle the baby tightly with a soft blanket, massage the babys abdomen, and place the infant in an upright seat after a feeding to help relieve colic. DIF: Cognitive Level: Applying REF: MCS: 471 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n6t.eAgrintyew parent relates to the nurse that the family has many known food allergies. Which is considered a primary strategy for feeding the infant with many family food allergies? a. Using soy formula for feeding b. Maternal avoidance of cows milk protein c. Exclusive breastfeeding for 4 to 6 months d. Delaying the introduction of highly allergenic foods past 6 months ANS: C Exclusive breastfeeding for 4 to 6 months is now considered a primary strategy for avoiding atopy in families with known food allergies; however, there is no evidence that maternal avoidance (during pregnancy or lactation) of cows milk protein or other dietary products known to cause food allergy will prevent food allergy in children. Researchers indicate that delaying the introduction of highly allergenic foods past 4 to 6 months of age may not be as protective for food allergy as previously believed. Likewise, studies have shown that soy formula does not prevent allergic disease in infants. DIF: Cognitive Level: Analyzing REF: MCS: 460 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 27. A bfeodttilne-fant has been diagnosed with cows milk allergy. Which formula should the nurse expect to be prescribed for the infant? a. Similac b. Pregestimil c. Enfamil with iron d. Gerber Good Start ANS: B For infants with cows milk allergy, the formula will be changed to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum) in which the protein has been broken down into its amino acids through enzymatic hydrolysis. Similac, Enfamil with iron, and Gerber Good Start are cows milkbased formulas. DIF: Cognitive Level: Applying REF: MCS: 461 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 28. The nurse is collecting a stool msaple from an infant pH should the nurse expect as the result? a. 5.5 b. 7.0 c. 7.5 d. 8 ANS: A twhil actose intolerance. Which fecal An acidic pH (55.5) indicates malabsorption, which occurs with lactose intolerance. The normal pH of the stool is 7.0 to 7.5. A finding of 8 would be alkaline. DIF: Cognitive Level: Analyzing REF: MCS: 462 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 29. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of inadequate caloric intake. The nurse understands that the reason for the FTT is most likely related to what? a. Cows milk allergy b. Congenital heart disease c. Metabolic storage disease d. Incorrect formula preparation ANS: D FTT classified according to the pathophysiology of inadequate caloric intake is lraeted to incorrect formula preparation, neglect, food fads, excessive juice poverty, breastfeeding problems, behavioral problems affecting eating, parental restriction of caloric intake, or central nervous system problems affecting intake consumption. Cows milk allergy would be related to the pathophysiology of inadequate absorption, congenital heart disease would be related to the pathophysiology of increased metabolism, and metabolic storage disease is related to defective utilization. DIF: Cognitive Level: Analyzing REF: MCS: 463 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 30. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for ethFTT i s most likely related to what? a. Cystic fibrosis b. Hyperthyroidism c. Congenital infection d. Breastfeeding problems ANS: C FTT classified according to the pathophysiology of defective utilization is related to a genetic anomaly, congenital infection of metabolic storage disease. Cystic fibrosis would be related to the pathophysiology of inadequate absorption, hyperthyroidism would be related to the pathophysiology of increased metabolism, and breastfeeding problems are related todienqauate caloric intake. DIF: Cognitive Level: Analyzing REF: MCS: 463 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 31. The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for hfuerrt t eaching? a. We will continue to use the 24-kcal/oz formula. b. We will be sure to follow the formula preparation instructions. c. We will be sure to give our infant at least 8 oz of juice every day. d. We will be sure to feed our infant according to the written schedule. ANS: C Juice intake in infants with FTT should be withheld until adequate weight gain has been achieved with appropriate milk sources; thereafter, no more than 4/oz day of juice should be given. Further teaching disendeief the parents indicate 8 oz of juice is allowed. For infants with FTT, 24-kcal/oz formulas may be provided to increase caloric intake. Because maladaptive feeding practices often contribute to growth failure, parents should follow specific step-by-step directions forufloarmpreparation, as well as a written lsechoefdu feeding times. Statements by the parents indicating they will use a 24-kcal/oz formula, follow directions for formula preparation, and feed their infant on schedule are accurate statements. DIF: Cognitive Level: Applying REF: MCS: 463 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is teaching parents about caring for their infant with seborrheic dermatitis (cradle cap). Which statement by the parents indicates understanding of the teaching? a. We will rinse off the shampoo quickly and dry the scalp thoroughly. b. We will shampoo the hair every other day with antiseborrheic shampoo. c. We will be sure to shampoo the hair without removing any of the crusts. d. We will use a fine-tooth comb to help remove the loosened crusts from the strands of hair. ANS: D A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing. This is an accurate statement. Shampoo should applied to the scalp and allowed to remain on the scalp until the crusts soften. Shampoo should not be rinsed off quickly. The crusts should be removed, and shampooing with antiseborrheic shampoo should be done daily, not every other day. DIF: Cognitive Level: Applying REF: MCS: 467 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 33. The nurse is administering an oral iahnitstamine datibmee to a c hild with iactop dermatitis (eczema). Which antihistamine should tnhuer se expect to be prescribed at bedtime? a. Cetirizine (Zyrtec) b. Loratadine (Claritin) c. Fexofenadine (Allegra) d. Diphenhydramine (Benadryl) ANS: D Oral antihistamine drugs such as hydroxyzine or diphenhydramine usually relieve moderate or severe pruritus. Nonsedating antihistamines such as cetirizine (Zyrtec), loratadine (Claritin), or fexofenadine (Allegra) may be fpre erred fdoarytime pr uritus relief. Because pruritus increases at night, a mildly sedating antihistamine such as Benadryl is prescribed. DIF: Cognitive Level: Applying REF: MCS: 469 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is planning care for an infant with eczema. Which interventions should the nurse include in the care plan? (Select all that apply.) a. Avoid giving the infant a bubble bath. b. Avoid the use of a humidifier in the infants room. c. Avoid overdressing the infant. d. Avoid the use of topical steroids on the infants skin. e. Avoid wet compresses on the infants most affected areas. ANS: A, C Guidelines for care of an infant with leucdzema inc avoiding a bubble bath and harsh soaps and avoiding overdressing the infant to prevent perspiration, which can cause a flare-up. The care plan should include using a humidifier in the infants room, topical steroids, and wet compresses on the most affected areas. DIF: Cognitive Level: Applying REF: MCS: 469 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 2. The community health nurse is reviewing risk factors for vitamin D deficiency. Which children earat high risk for vitamin D deficiency? (Select all that apply.) a. Children with fair pigmentation b. Children who are overweight or obese c. Children who are exclusively bottle fed d. Children with diets low in sources of vitamin D e. Children of families who use milk products not supplemented with vitamin D ANS: B, D, E Populations at risk for vitamin D deficiency winecilguhdte over or obese children, children with diets low in sources of vitamin D, and children of families who use milk products not supplemented with vitamin D. Children with dark, not fair, pigmentation and children who are exclusively breast fed, not bottle fed, are also at risk. DIF: Cognitive Level: Analyzing REF: MCS: 453 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 3. The nurse has administered a dose of epinephrine to a 12-month-old infant. For which adverse reactions of epinephrine should the nurse monitor? (Select all that apply.) a. Nausea b. Tremors c. Irritability d. Bradycardia e. Hypotension ANS: A, B, C Epinephrine increases activation of the sympathetic nervous system. Adverse effects include nausea, tremors, and irritability. Tachycardia would occur, not bradycardia, and hypertension, not hypotension, would occur. DIF: Cognitive Level: Applying REF: MCS: 459 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant? (Select all that apply.) a. Fear of strangers b. Minimal smiling c. Avoidance of eye contact d. Meeting developmental milestones e. Wide-eyed gaze and continual scan of the environment ANS: B, C, E Signs and symptoms of FTT include minimal smiling, avoidance of eye contact, dane-deayewdi gaze and continual scan of the environment (radar gaze). There is no fear of strangers, and there are developmental delays, including social, motor, adaptive, and language. DIF: Cognitive Level: Analyzing REF: MCS: 463 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is preparing to feed a 10-month-old child gdinaosed w ith iflaure to thrive (F TT). Which actions should the nurse plan to implement? (Select all that apply.) a. Be persistent. b. Introduce new foods slowly. c. Provide a stimulating atmosphere. d. Maintain a calm, even temperament. e. Feed the infant only when signs of hunger are exhibited. ANS: A, B, D Feeding strategies for children with FTT should include persistence; introducing new foods slowly; and maintaining a calm, even temperament. The environment should be unstimulating, and a structured routine should be developed with regard to feeding, not just when the infant shows signs of hunger. DIF: Cognitive Level: Applying REF: MCS: 463 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion andiMnteanance 6. The nurse is teaching parents about foods that are hyperallergenic. Which foods should the nurse include? (Select all that apply.) a. Peanuts b. Bananas c. Potatoes d. Egg noodles e. Tomato juice ANS: A, D, E Hyperallergenic foods include peanuts, egg noodles, and tomato juice. Bananas and potatoes are not hyperallergenic. DIF: Cognitive Level: Applying REF: MCS: 470 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session? (Select all that apply.) a. Overeating b. Understimulation c. Frequent burping d. Parental smoking e. Swallowing excessive air ANS: A, D, E Potential causes of colic include too rapid feeding, overeating, swallowing excessive air, improper feeding technique (especially in positioning and burping), emotional stress or tension between the parent and child, parental smoking, and overstimulation. DIF: Cognitive Level: Applying REF: MCS: 470 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. What are risk factors for suddenfiannt death syndrome? (Select all .t)hat apply a. Postterm b. Female gender c. Low Apgar scores d. Recent viral illness e. Native American infants ANS: C, D, E Infant risk factors for sudden infant death syndrome include those with low Apgar scores and recent viral illness and Native American infants. Preterm, not postterm, birth and male, not female, gender are other risk factors. DIF: Cognitive Level: Understanding REF: MCS: 475 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 9. The nurse is teaching parents strategies to manage their childs refusal to go to sleep. Which should the nurse include in the teaching session? (Select all that apply.) a. Keep bedtime early. b. Enforce consistent limits. c. Use a reward system with the child. d. Have a consistent before bedtime routine. ANS: B, C, D Strategies to manage a childs refusal to go to sleep include enforcement of consistent limits, using a reward system, and having a consistent before bedtime routine. An evaluation of whether the hour of sleep is too early should be considered because an early bedtime could cause the child to resist sleep if not tired. Chapter 12.Health Promotion of the Toddler and Family MULTIPLE CHOICE 1. What factor is most important in predisposing toddlers to frequent infections? a. Respirations are abdominal. b. Pulse and respiratory rates in toddlers are slower than those in infants. c. Defense mechanisms are less efficient than those during infancy. d. Toddlers have short, straight internal ear canals and large lymph tissue. ANS: D Toddlers continue to have the short, straight internal ear canals of infants. The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose toddlers to frequent infections. The abdominal respirations and lowered pulse and respiratory rate of toddlers do not eacfft their susceptibility to infection. The defense mechanisms are more efficient compared with those of infancy. DIF: Cognitive Level: Analyzing REF: MCS: 490 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. What do the psychosocial developmental tasks of toddlerhood include? a. Development of a conscience b. Recognition of sex differences c. Ability to get along with age mates d. Ability to delay gratification ANS: D If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that toddlers are concerned with is the ability to delay gratification. Development of a conscience and recognition of sex differences occur during the preschool years. The ability to get along with age mates develops during the preschool and school-age years. DIF: Cognitive Level: Understanding REF: MCS: 490 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. The developmental task with which the child of 15 to 30 months is likely to be struggling is a sense of which? a. Trust b. Initiative c. Intimacy d. Autonomy ANS: D Autonomy versus shame and doubt is the developmental task of toddlers. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of early childhood. Intimacy and solidarity versus isolation is the developmental stage of early adulthood. DIF: Cognitive Level: Remembering REF: MCS: 490 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Parents of an 18-month-old boy tells the nurse that he says no to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. What is the nurses best interpretation of this behavior? a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention. ANS: A Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and use of the word no. Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old. DIF: Cognitive Level: Understanding REF: MCS: 491 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. A 17-month-old child should be expected to be in which stage, according to Piaget? a. Preoperations b. Concrete operations c. Tertiary circular reactions d. Secondary circular reactions ANS: C A 17-month-old is in the fifth stage of the sensorimotor phase, tertiary circular reactions. The child uses active experimentation to achieve previously unattainable goals. Preoperations is the stage of cognitive development usually present in older toddlers and preschoolers. Concrete operations is the cognitive stage associated with school-age children. The secondaryrcciular reaction stage lasts from about ages 4 to 8 months. DIF: Cognitive Level: Understanding REF: MCS: 491 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 6. Although a 14-month-old girl received a shock from an electrical outlet recently, her parent finds her about to place a paper cliphienraonuottlet. W hich is the best interpretation of this behavior? a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of toddlers inability to transfer remembering to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain. ANS: C During the utertiary circ lar reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for stheechildren. The slot of an outlet is for putting things into. This is typical behavior for a toddler, who is only somewhat aware of a causal relation between events. Her cognitive development oisparipapter for her age. DIF: Cognitive Level: Understanding REF: MCS: 491 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 7. A toddler, age 16 tmhos,nf alls down a few rssta. iH e gets uspcoand caused him to fall. What is this an example of? a. Animism b. Ritualism lds the stairs as if they c. Irreversibility d. Delayed cognitive development ANS: A Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing humanrcha acteristics to them. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to toddlers. Irreversibility is the ilniatyb to re verse or undo actions initiated physically. The toddler is acting in an age-appropriate manner. DIF: Cognitive Level: Analyzing REF: MCS: 493 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 8. What is a characteristic of a toddlers language development at age 18 months? a. Vocabulary of 25 words b. Use of holophrases c. Increasing level of understanding d. Approximately one third of speech understandable ANS: C During the second year of life, the understanding and understanding of speech increase to a level far greater than the childs vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. An 18-month-old child bhuaslaaryvof a approximately 10 words. At this age, the child does not use the one-word sentences that are characteristic of 1-year-old children. The child has a very limited vocabulary of single words that are comprehensible. DIF: Cognitive Level: Understanding REF: MCS: 493 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Health Promotion and Maintenance 9. Which characteristic best describes the gross motor skills of a 24-month-old child? a. Skips b. Broad jumps c. Rides tricycle d. Walks up and down stairs ANS: D A 24-month-old child can go up and down stairs alone with two feet on each step. Skipping and broad jumping are skills acquired at age 3 years. Tricycle riding is achieved at age 4 years. DIF: Cognitive Level: Understanding REF: MCS: 514 TOP: NursoicnegssP:rAssessment iMenStC: Cl Needs: Health Promotion and Maintenance 10. What developmental characteristic does not occur lunatci hild reaches age 2 1/2 y ears? a. Birth weight has doubled. b. Anterior fontanel is still open. c. Primary dentition is complete. d. Binocularity may be established. ANS: C Usually by age 30 months, the primary dentition of 20 teeth is complete. Birth weight doubles at approximately ages 5 to 6 months. The anterior fontanel closes at ages 12 to 18 months. Binocularity is established by age 15 months. DIF: Cognitive Level: Understanding REF: MCS: 499 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 11. Which statement is correct about toilet training? a. Bladder training is usually accomplished before bowel training. b. Wanting to please the parent helps motivate the child to use the toilet. c. Watching older siblings use the toilet confuses the child. d. Children must be forced to sit on the toilet when first learning. ANS: B Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to nledt tgoohaold on. The child must want to please the parent by holding on rather than pleasing him- or herself by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the rto. ddle nonthreatening manner. The lcdhis ohuld be introduced to the potty chair or toilet in a DIF: Cognitive Level: Understanding REF: MCS: 500 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 12. The parents of a newborn say that their toddler hates the baby. He suggested that we put him in the trash can so the trash truck could take him away. What is the nurses best reply? a. Lets see if we can figure out why he hates the new baby. b. Thats a strong statement to come from such a small boy. c. Lets refer him to counseling to work this hatred out. Its not a normal response. d. That is a normal response to the birth of a sibling. Lets look at ways to deal with this. ANS: D The arrival of a new infant represents a crisis for even the best prepared toddler. Toddlers have their entire schedules and routines disrupted because of the new family member. The nurse should work with the parents on ways to involve the toddler in the newborns care and to help focus attention on the toddler. The toddler does not hate the infant. This is an expected, normal response to the changes in routines and attention that affect the toddler. The toddler can be provided with a doll to imitate parents behaviors. The child can care for the dolls needs at the same time the parent is performing similar care for the newborn. DIF: Cognitive Level: Understanding REF: MCS: 502 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 13. A toddlers parent asks the nurse for suggestions on dealing with temper tantrums. What is the most appropriate recommendation? a. Punish the child. b. Explain to child that this is wrong. c. Leave the child alone until the tantrum is over. d. Remain close by the child but without eye contact. ANS: D The best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common during this age group as the child ebsecom more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. Tprheesen ce of the parent is necessary both for ysaafentd to provide a feeling of control and security to the child when the tantrum is over. DIF: Cognitive Level: Understanding REF: MCS: 503 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 14. A parent asks the nurse about negativism in toddlers. What is the most appropriate recommendation? a. Punish the child. b. Provide more attention. c. Ask child not to always say no. d. Reduce the opportunities for a no answer. ANS: D The nurse should suggest to the parent that questions should be phrased with realistic choices rather than yes or no answers. This provides a sense of control for the toddler and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to comply with requests not to say no. DIF: Cognitive Level: Analyzing REF: MCS: 503 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 15. The parents of a 2-year-old child tell the nurse they are concerned because the toddler has started to use baby talk since the arrival of their new baby. What should the nurse recommend? a. Ignore the baby talk. b. Tell the toddler frequently, You are a big kid now. c. Explain to the toddler that baby talk is for babies. d. Encourage the toddler to practice more advanced patterns of speech. ANS: A Baby talk is a sign of regression in the toddler. Oftenrtsoadtdtelempt to c ope with raestsful situation by reverting to patterns of behavior that were successful in earlier stages of development. It should be ignored while the parents praise the child for developmentally appropriate behaviors. Regression is childrens way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism. DIF: Cognitive Level: Applying REF: MCS: 504 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 16. Parents tell the nurse that their toddler eats little at mealtime, only sits at the table with the family briefly, and wants snacks all the time. What should the nurse recommend? a. Give her nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so she is hungry at mealtimes. d. Explain to her in a firm manner what is expected of her. ANS: A Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirements associated with the wsloer growth rate. P arents should asisst the child in developing healthy eating habits. Toddlers are often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should be not be used as positive or negative reinforcement for behavior. The child may develop habits of overeating or eat non-nutritious foods in response. A toddler is not able to understand explanations of what is expected of her and comply with the expectations. DIF: Cognitive Level: Applying REF: MCS: 505 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is what? a. A sign the child is spoiled b. An attempt to exert unhealthy control c. Regression, which is common at this age d. Ritualism, an expected behavior at this age ANS: D The child is exhibiting the ritualism, which is characteristic at teh. iRs ag itualism is the need to maintain sameness and reliability. It provides a sense of structure and comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. This does not indicate the child has unreasonable expectations but rather is part of anlodrmevelopment. R itualism is not regression, which is a retreat from a present pattern of functioning. DIF: Cognitive Level: Analyzing REF: MCS: 491 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 18. The nurse is discussing with a parent group the importance of fluoride for healthy teeth. What should the nurse recommend? a. Determine whether the water supply is fluoridated. b. Use fluoridated mouth rinses in children older than 1 year. c. Give fluoride supplements to infants beginning at age 2 months. d. Brush teeth with fluoridated toothpaste unless the fluoride content of water supply is adequate. ANS: A The decision about fluoride supplementation cannot be made until it is known whetherttehre wa supply contains fluoride and the amount. It is difficult to teach toddlers to spit out mouthwash. Swallowing fluoridated mouthwashes can contribute to fluorosis. Fluoride supplementation is not recommended until after age 6 months and then only if the water is not fluoridated. Fluoridated toothpaste is still indicated if the fluoride content of the water supply is adequate, but very small amounts are used. DIF: Cognitive Level: Analyzing REF: MCS: 510 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. Which is an appropriate recommendation in preventing tooth decay in young children? a. Substitute raisins for candy. b. Substitute sugarless gum for regular gum. c. Use honey or molasses instead of refined sugar. d. When sweets are to be eaten, select a time not during meals. ANS: B Regular gum has high sugar content. When the child chews gum, the sugar is in prolonged contact with the teeth. Sugarless gum is less cariogenic than regular gum. Raisins, honey, and molasses are highly cariogenic and should be avoided. Sweets should be consumed with meals so that the teeth can be cleaned afterward. This decreases the amount of mti e that t he sugar is in contact with the teeth. DIF: Cognitive Level: Analyzing REF: MCS: 511 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 20. What is the leading cause of death during the toddler period? a. Injuries b. Infectious diseases c. Childhood diseases d. Congenital disorders ANS: A Injuries are the most common cause of death in children ages 1 through 4 years. It is the highest rate of death from injuries of any childhood age group except adolescence. Congenital disorders are the second leading cause of death in this age group. Infectious and childhood diseases are less common causes of death in this age group. DIF: Cognitive Level: Understanding REF: MCS: 512 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 21. The parent of 16-month-old child asks, What is the best way to keep my child from getting into our medicines at home? What should the nurse advise? a. All medicines should be locked securely away. b. The medicines should be placed in high cabinets. c. Your child just needs to be taught not to touch medicines. d. Medicines should not be kept in the homes of small children. ANS: A The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize that all the different rfoms of medications inethhom e may be dangerous. Keeping medicines out of thoem es of small children is not feasible because many parents require medications for chronic or acute illnesses. Parents must be taught safe storage for their home and when they visit other homes. DIF: Cognitive Level: Applying REF: MCS: 512 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. Parents are switching their toddler, who has met the weight requirement, from a rear-facing car seat to a forward-facing seat. The nurse should recommend the parents place the seat where in the car? a. In the front passenger seat b. In the middle of the rear seat c. In the rear seat behind the driver d. In the rear seat behind the passenger ANS: B Children 0 to 3 years of age riding properly restrained in the middle of the backseat have a 43% lower risk of injury than children riding in the outboard (window) seat during a crash. DIF: Cognitive Level: Applying REF: MCS: 514 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 23. What is the most common type of burn in the toddler age group? a. Electric burn from electrical outlets b. Flame burn from playing with matches c. Hot object burn from cigarettes or irons d. Scald burn from high-temperature tap water ANS: D Scald burns are the most common type of thermal injury in children, especially 1- and 2-year-old children. Temperature should be reduced on the hot water in the house and hot liquids placed out of the childs reach. eEcltric burns from electrical outlets and hot object burns from cigarettes or irons are both significant causes of burn injury. The child should be protected by reducing the temperature on the hot ewraht eater in thhoeme, keeping objects such as cigarettes and irons away from children, and placing protective guards over electrical outlets when not in use. Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age group but not one of the most common types of burn. DIF: Cognitive Level: Understanding REF: MCS: 515 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 24. The nurse is assessing a 20-month-old toddler during a well-child visit and notices tooth decay. The nurse should understand that early childhood caries are caused by what? a. Allowing the child to eat citrus foods at bedtime b. A hereditary factor that cannot be prevented c. Poor fluoride supply in the drinking water d. Giving the child a bottle of juice or milk at naptime ANS: D One cause of early childhood caries is allowing the child to go to sleep with a bottle of milk or juice; as the sweet liquid pools in the mouth, the teeth are bathed for several hours in this cariogenic environment. Eating citrus fruit at bedtime and poor fluoride supply in drinking water do not cause early childhood caries. The problem is not hereditary and can be prevented with proper education. DIF: Cognitive Level: Understanding REF: MCS: 511 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 25. The nurse is providing guidance strategies to a group of parents with toddlers at a community outreach program. Which statement by a parent indicates a correct understanding of the teaching? a. I should expect my 24-month-old child to express some signs of readiness for toilet training. b. I should be firm and structured when disciplining my 18-month-old child. c. I should expect my 12-month-old child to start to develop a fear of darkness and to need a security blanket. d. I should expect my 36-month-old child to understand time and proximity of events. ANS: A A 24-month-old toddler starts to show rdeinaess for toilet training; it is important for the nptare to be aware of this and be ready to start the process. At 18 months of age, a child needs consistent but gentle discipline because the child cannot yet understand firmness and structure with discipline. Development of fears and need for security items usually occurs at the end of the 18- to 24-month stage. A 36-month-old child does not yet understand time and proximity of events, so the parent needs to understand that the toddler cannot hurry up or we will be late. DIF: Cognitive Level: Applying REF: MCS: 518 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 26. The nurse is assessing a toddlers visual acuity. Which visual acuity iosncsidered acceptable during the toddler years? a. 20/20 b. 20/40 c. 20/50 d. 20/60 ANS: B Visual acuity of 20/40 is considered acceptable during the toddler years. DIF: Cognitive Level: Analyzing REF: MCS: 488 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 27. The nurse is teaching parents about toilet training. What should the nurse include in the teaching session? a. Bladder training is accomplished before bowel training. b. The mastery of skills required for toilet training is present at 18 months. c. By 12 months, the child is able to retain urine for up to 2 hours or longer. d. The physiologic ability to control the sphincters occurs between 18 and 24 months. ANS: D The physiologic ability to control the sphincters occurs somewhere between ages 18 and 24 months. Bowel training is usually accomplished before bladder training because of its greater regularity and predictability. The mastery of skills required for training are not present before 24 months of age. By 14 to 18 months of age, the child is able to retain urine for up to 2 hours or longer. DIF: Cognitive Level: Applying REF: MCS: 489 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. The nurse is planning care for a hospitalized toddler. What is the rationale for planning to continue the toddlers rituals while hospitalized? a. To provide security b. To prevent regression c. To prevent dependency d. To decrease negativism ANS: A Ritualism, the need to maintain sameness and reliability, provides a sense of security and comfort. It will not prevent regression or dependency or decrease negativism. DIF: Cognitive Level: Applying REF: MCS: 491 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 29. A nurse is observing children playing in the playroom. What describes parallel play? a. A child playing a video game b. Two children playing a card game c. Two children watching a movie on a television d. A child playing with blocks next to a child playing with trucks ANS: D Parallel play is when eartopdladyls iadloen, gnso ith,t w eoth r children. A child ypliang w ith blocks next to a child playing with trucks is descriptive of parallel play. The child playing a video game is descriptive of solitary play. Two children playing cards is descriptive of cooperative play. Two children watching a television is descriptive of associative play. DIF: Cognitive Level: Analyzing REF: MCS: 497 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 30. Parents ask the nurse for strategies to help their toddler adjust to a new baby. What should the nurse suggest? a. Start talking about the baby very early in the pregnancy. b. Move the toddler to a new bed after the baby comes home. c. Tell the toddler that a new playmate will be coming home soon. d. Alert visitors to the new baby to include the toddler in the visit. ANS: D Parents can minimize sibling rivalry by alerting visitors to the toddlers needs, having small presents on hand for the toddler, and including the child in the visits as much as possible. Time is a vague concept for toddlers. A good time to start talking about the new baby is when the toddler becomes aware of the pregnancy and the changes occurring in the home in anticipation of the new member. To avoid additional stresses when the newborn arrives, parents should perform anticipated changes, such as moving the toddler to a different room or bed, well in advance of the birth. Telling the toddler that a new playmate will come home soon sets up unrealistic expectations. DIF: Cognitive Level: Applying REF: MCS: 502 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 31. Parents ask the nurse, How should we deal with our toddlers regression since our new baby has come home? The nurse should give the parents which response? a. Introduce new areas of learning. b. Use time-out as punishment when regression occurs. c. Ignore the behavior and praise appropriate behavior. d. Explain to the toddler that the behavior is not acceptable. ANS: C When regression does occur, the best approach is to ignore it while praising existing patterns of appropriate behavior. It is advisable not to introduce new areas of learning when an additional crisis is present or expected, such as beginning toilet training shortly before a sibling is born or during a brief hospitalization. Time-out should not be used as a punishment, and the toddler does not have the cognitive ability to understand an explanation that the behavior is not acceptable. DIF: Cognitive Level: Applying REF: MCS: 504 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 32. The nurse understands that which guideline should be followed to determine serving sizes for toddlers? a. 1/2 tbsp of solid food per year of age b. 1 tbsp of solid food per year of age c. 2 tbsp of solid food per year of age d. 2 1/2 tbsp of solid food per year of age ANS: B To determine serving sizes for young children, the guideline to follow is 1 tbsp of solid food per year of age. One-half tbsp per year of age would not be adequate. Two or 2 1/2 tbsp per year of age would be excessive. DIF: Cognitive Level: Understanding REF: MCS: 505 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 33. The enuisrst eaching parents about avoiding accidental burns with their toddler. What water heater setting should the nurse recommend to the parents? a. 120 F b. 130 F c. 140 F d. 150 F ANS: A The water heater shouldmbeit sheotutos li ehold water temperatures to less than 49 C (120 F). At this temperature, it takes 10 minutes for oextphoeswuraetetr to cause la-tfhuilckness burn. Conversely, water temperatures of 54 C (130 F), the usual setting of most water heaters, expose household members to the risk of full-thickness burns within 30 seconds. DIF: Cognitive Level: Applying REF: MCS: 516 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 34. To avoid a fall from a crib, the nurse recommends to parents that their toddler should sleep in a bed rather than a crib when reaching what height? a. 30 in b. 35 in c. 40 in d. 45 in ANS: B When children reach a height of 89 cm (35 in), they should sleep in a bed rather than a crib. DIF: Cognitive Level: Applying REF: MCS: 517 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is preparing a staff education program about growth and development of an 18- month-old toddler. Which characteristics should the nurse include in the staff education program? (Select all that apply.) a. Eats well with a spoon and cup b. Runs clumsily and can walk up stairs c. Points to common objects d. Builds a tower of three or four blocks e. Has a vocabulary of 300 words f. Dresses self in simple clothes ANS: A, B, C, D Tasks accomplished by mano1n8th--old toddler include eating well with a spoon and cup, running clumsily, walking up stairs, pointing to common objects such as shoes, and building a tower with three or four blocks. An 18-month-old toddler has a vocabulary of only 10 words, not 300. Toddlers cannot dress themselves in simple clothing until 24 months of age. DIF: Cognitive Level: Applying REF: MCS: 490 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. A parent asks the nurse, When will I know my child is ready for toilet training? The nurse should include what in the response? (Select all that apply.) a. The child should be able to stay dry for 1 hour. b. The child should be able to sit, walk, and squat. c. The child should have regular bowel movements. d. The child should express a willingness to please. ANS: B, C, D Signs of toilet training readiness include physical and psychological readiness. The ability to sit, walk, and squat and having regular bowel movements are physical readiness signs. Expressing a willingness to please is a sign of psychological readiness. The child should be able to stay dry for 2 hours, not 1. DIF: Cognitive Level: Applying REF: MCS: 500 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. The nurse is teaching parents of a toddler how to handle temper tantrums. What should the nurse include in the teaching? (Select all that apply.) a. Provide realistic expectations. b. Avoid using rewards for good behavior. c. Ensure consistency among all caregivers in expectations. d. During tantrums, ignore the behavior and continue to be present. e. Use time-outs for managing temper tantrums, starting at 12 months. ANS: A, C, D The best approach toward tapering temper tantrums requires consistency and developmentally appropriate expectations and rewards. Ensuring consistency among all caregivers in expectations, prioritizing what rules are important, and developing consequences that are reasonable for the childs level of development help manage the behavior. During tantrums, ignore the behavior, provided the behavior is not injurious to the child, such as violently banging the head on the floor. Continue to be present to provide a feeling of control and security to the child after the tantrum has subsided. Starting at 18 months, time-outs work well for managing temper tantrums, but not at 12 months. DIF: Cognitive Level: Applying REF: MCS: 503 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. What preventive measures should athce nurse te childhood caries? (Select all that apply.) a. Avoid using a bottle as a pacifier. b. Eliminate bedtime bottles completely. c. Place juice in a bottle for the child to drink. d. Wean from the bottle by 18 months of age. e. Avoid coating pacifiers in a sweet substance. ANS: A, B, E h parents of toddlers to prevent early Prevention of dental caries involves eliminating ithmeebedt bottle completely, feeding the last bottle before bedtime, substituting a bottle of water for milk or juice, not using the bottle as a pacifier, and never coating fpiaecri s in sweet substances. Juice in bottles, especially commercially available ready-to-use bottles, is discouraged; these beverages are especially damaging because the sugar is more readily converted to acid. Juice should always be offered in a cup to avoid prolonging the bottle-feeding habit. Toddlers should be encouraged to drink from a cup at the first birthday and weaned from a bottle by 14 months of age, not 18 months. DIF: Cognitive Level: Applying REF: MCS: 512 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. A toddler is in the sensorimotor, tertiary circular reactions stage of cognitive development. What behavior should the nurse expect to assess? (Select all that apply.) a. Refers to self by pronoun b. Gestures up and down c. Able to insert round object into a hole d. Can find hidden objects but only in the first location e. Uses future-oriented words, such as tomorrow ANS: B, C, D Children in the sensorimotor, tertiary circular reactions stage of cognitive development show the behaviors of gesturing up and down, have the ability to insert round objects into a hole, and can find hidden objects but only in the first location. The behaviors of referring to oneself by pronoun and using future-orriednstseudcwh oas tomorrow are seen in the preoperational stage of cognitive development. DIF: Cognitive Level: Applying REF: MCS: 492 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion andtMenannce 6. The nurse is teaching a parent of an 18-month-old about developmental milestones associated with feeding. What should the nurse include in the teaching? (Select all that apply.) a. The child will begin to use a fork. b. The child will be able use a straw and cup. c. The child will be able to hold a cup with both hands. d. The child will be able to drink from a cup with a lid. e. The child will begin to use a spoon but may turn it before reaching the mouth. ANS: C, D, E An 18-month-old child can hold a cup with both hands, is able to drink from a cup with a lid, and begins to use a spoon but may turn it before reaching the mouth. Using a fork is a developmental milestone of a 36-month-old child. Using a straw and cup is a milestone seen at 24 months. DIF: Cognitive Level: Applying REF: MCS: 505 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is preparing to administer some iron drops to a toddler. Which factor can increase iron absorption? (Select all that apply.) a. Vitamin A b. Acidity (low pH) c. Phosphates (milk) d. Malabsorptive disorders e. Ascorbic acid (Vitamin C) ANS: A, B, E Factors that increase iron absorption are vitamin A, acidity ,(laonwd paHsc)orbic acid (vitamin C). Phosphates (milk) and malabsorptive disorders decrease absorption of iron. DIF: Cognitive Level: Applying REF: MCS: 508 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 8. A parent tells the nurse, My toddler tries to undo the car seat harness and climb out of the seat. What strategies should the nurse recommend to the parent to encourage the child to stay in the seat? (Select all that apply.) a. Allow your child to hold a favorite toy. b. Allow your child out of the seat occasionally. c. Avoid using rewards to encourage cooperative behavior. d. When child tries to unbuckle the seat harness, firmly say, No. e. It may be necessary to stop the car to reinforce the expected behavior. ANS: A, D, E Strategies to genecaoura child to stay in a car seat include allowing the child to hold favorite toy, firmly saying No if the child begins to undo the harness, and stopping the car to reinforce the expected behavior. Rewards, such as stars or stickers, can be used touenco rage cooperative behavior. The child should stay in the car seat at all times, even for short trips. DIF: Cognitive Level: Analyzing REF: MCS: 512 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 9. What child behavior indicates to the nurse that temperutmanstrhave become a problem? (Select all that apply.) a. The child is 2 to 3 years old b. Tantrums occur at bedtime c. Tantrums occur past 5 years of age d. Tantrums last longer than 15 minutes e. Tantrums occur more than five times a day ANS: C, D, E Temper tantrums are common during the toddler years and essentially represent normal developmental behaviors. However, temper tantrums can be signs of serious problems. Temper tantrums that occur past 5 years of age, last longer than 15 minutes, or occur more than five times a day are considered abnormal and may indicate a serious problem. A popular time for a tantrum is before bedtime. Chapter 13.Health Promotion of the Preschooler and Family MULTIPLE CHOICE 1. In terms of fine motor development, what should the 3-year-old child be expected to do? a. Tie shoelaces. b. Copy (draw) a circle. c. Use scissors or a pencil very well. d. Draw a person with seven to nine parts. ANS: B Three-year-old children are able to accomplish the fine motor skill of copying (drawing) a circle. The ability to tie shoelaces, to use scissors or a pencil very well, and to draw a person with seven to nine parts are fine motor skills of 5-year-old children. DIF: Cognitive Level: Understanding REF: MCS: 523 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 2. According to Piaget, magical thinking is the belief of which? a. Thoughts are all powerful. b. God is an imaginary friend. c. Events have cause and effect. d. If the skin is broken, the insides will come out. ANS: A Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are all powerful. Believing God is an imaginary friend is an example of concrete thinking in a preschoolers spiritual development. Cause-and-effect implies logical thought, not magical thinking. Believing that if the skin is broken, the insides will come out is an example of concrete thinking in development of body image. DIF: Cognitive Level: Understanding REF: MCS: 526 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. In terms of cognitive development, a 5-year-old child should be expected to do which? a. Think abstractly. b. Use magical thinking. c. Understand conservation of matter. d. Understand another persons perspective. ANS: B Magical thinking is believing that thoughts can cause events. An example is thinking of the death of a parent might cause it to happen. Abstract thought does not develop until the school-age years. The concept of conservation is the cognitive task of school-age children, ages 5 to 7 years. A 5-year-old child cannot understand another persons perspective. DIF: Cognitive Level: Understanding REF: MCS: 525 TOP: Nursing Process: Assessment :MSC Client Needs: Health Promotion and Maintenance 4. The nurse is caring for a hospitalized 4-year-old boy. His parents tell the nurse they will be back to visit at 6 PM. When he asks the nurse when his parents are coming, what would the nurses best response be? a. They will be here soon. b. They will come after dinner. c. Let me show you on the clock when 6 PM is. d. I will tell you every time I see you how much longer it will be. ANS: B A 4-year-old child understands time in relation to events such as meals. Children perceive soon as a very short time. The nurse may lose the childs trust if his parents do not return in the time he perceives as soon. Children cannot read or use a clock for practical purposes until age 7 years. I will tell you every teimI see you how much longer it will be assumes the child understands the concepts of hours and minutes, which does not occur until age 5 or 6 years. DIF: Cognitive Level: Understanding REF: MCS: 525 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. A 4-year-old boy is phoitsalized with a s erious tbearcial infection. He tells the nurse that he is sick because he was bad. What is the nurses best interpretation of this comment? a. Sign of stress b. Common at this age c. Suggestive of maladaptation d. Suggestive of excessive discipline at home ANS: B Preschoolers cannot understand the cause and effect of illness. Their engtorcism makes them think they are directly responsible for events, making them feel guilt for things outside of their control. Children of this age react to stress by regressing developmentally or acting out. Maladaptation is unlikely. This comment does not imply excessive discipline at home. DIF: Cognitive Level: Understanding REF: MCS: 526 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 6. A 4-year-old child tells the nurse that she doesnt want another blood sample drawn because I need all of my insides and I dont want anyone taking them out. What is the nurses best interpretation of this? a. The child is being overly dramatic. b. The child has a disturbed body image. c. Preschoolers have poorly defined body boundaries. d. Preschoolers normally have a good understanding of their bodies. ANS: C Preschoolers have little understanding of body boundaries, which leads to fears of mutilation. The child is not capable of being dramatic at this age. She truly has fear. Body image is just developing in school-age children. Preschoolers do not have good understanding of their bodies. DIF: Cognitive Level: Understanding REF: MCS: 527 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 7. Which type of play is most typical of the preschool period? a. Team b. Parallel c. Solitary d. Associative ANS: D Associative play is group play in similar or identical activities but without rigid organization or rules. School-age children play in teams. Parallel play is that of toddlers. Solitary play is that of infants. DIF: Cognitive Level: Understanding REF: MCS: 528 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 8. What characteristic best describes the language skills of a a3r-ye -old child? a. Asks meanings of words b. Follows directional commands c. Can describe an object according to its composition d. Talks incessantly regardless of whether anyone is listening ANS: D Because of the dramatic vocabularyrienacse at this age, 3 -year-old children are known to talk incessantly regardless of whether anyone is listening. A 4- to 5-year-old child asks lots of questions and can follow simple directional commands. A 6-year-old child can describe an object according to its composition. DIF: Cognitive Level: Understanding REF: MCS: 529 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 9. During a well-child visit, the father of a 4-year-old boy tells the nurse that he is not sure if his son is ready for kindergarten. The boys birthday is close to the cut-off date, and he has not attended preschool. What is the nurses best recommendation? a. Start kindergarten. b. Talk to other parents about readiness. c. Perform a developmental screening. d. Postpone kindergarten and go to preschool. ANS: C A developmental assessment with a screening tool thaaddresses cognitive, social, and physical milestones can help identify children who may need further assessment. A readiness assessment involves an evaluation of skill acquisition. Stating the child should start kindergarten or go to preschool and postpone kindergarten does not address the fathers concerns about readiness for school. Talking to other parents about readiness does not ascertain if the child is ready and does not address the fathers concerns. DIF: Cognitive Level: Applying REF: MCS: 532 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Parents tell the nurse they found their 3-year-old daughter and a male cousin of the same age inspecting each other closely as they used the bathroom. What is the most appropriate recommendation for the nurse to make? a. Punish the children so this behavior stops. b. Neither condone nor condemn the curiosity. c. Get counseling for this unusual and dangerous behavior. d. Allow the children unrestricted permission to satisfy this curiosity. ANS: B Three-year-old children become aware of anatomic differences and are concerned about how the other sex works. Such exploration should not be condoned or condemned. Children should not be punished for this normal exploration. This is age appropriate and not dangerous behavior. Encouraging the children to ask their parents questions and redirecting their activity is more appropriate than giving permission. DIF: Cognitive Level: Applying REF: MCS: 534 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 11. A boy age 4 1/2 years has been having increasingly frequent angry outbursts in preschool. He is aggressive toward the other children and the teachers. This behavior has been a problem for approximately 8 to 10 weeks. His parent asks the nurse for advice. What is the most appropriate intervention? a. Refer the child for a professional psychosocial assessment. b. Explain that this is normal in preschoolers, especially boys. c. Encourage the parent to try more consistent and firm discipline. d. Talk to the preschool teacher to obtain validation for behavior parent reports. ANS: A The preschool years are a time when children learn socially acceptable behavior. The difference between normal and problematic behavior is not the behavior but the severity, frequency, and duration. This childs behavior meets the definition requiring professional evaluation. Some aggressive behavior is withinanlolrimits, but at 8 to 10 weeks, this behavior has persisted too long. There is no indication that the parent is using inconsistent discipline. A part of the evaluation is to obtain validation for behavior parent reports. DIF: Cognitive Level: Applying REF: MCS: 525 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. What dysfunctional speech pattern is a normal characteristic of the language development of a preschool child? a. Lisp b. Echolalia c. Stammering d. Repetition without meaning ANS: C Stammering and stuttering are normal dysfluency in preschool-age children. Lisps are not a normal characteristic of language development. Echolalia and repetition are traits of toddlers language. DIF: Cognitive Level: Understanding REF: MCS: 536 TOP: Nursing Process: Assessment iMenStC: Cl Needs: Health Promotion and Maintenance 13. The parent of a 4-year-old boy tells the nurse that the child believes monsters and bogeymen are in his bedroom at night. What is the nurses best suggestion for coping with this problem? a. Let the child sleep with his parents. b. Keep a night light on in the childs bedroom. c. Help the child understand that these fears are illogical. d. Tell the child that monsters and bogeymen do not exist. ANS: B Involve the child in problem solving. A night light shows a child that imaginary creatures do not lurk in the rdkaness. L etting the iclhd s elpe w ith his parents will not get rid of athrse.fAe 4 - year-old child is in the preconceptual stage and cannot understand logical thought. DIF: Cognitive Level: Applying REF: MCS: 537 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 14. What is descriptive of the tniuotnrai l requirements of preschool children? a. The quality of the food consumed is more important than the quantity. b. The average daily intake of preschoolers should be about 3000 calories. c. Nutritional requirements for preschoolers are very different from requirements for toddlers. d. Requirements for calories per unit of body weight increase slightly during the preschool period. ANS: A Parents need to be reassured that the quality of food eaten is more important than the quantity. Children are able to self-regulate their intake when offered foods high in nutritional value. The average daily caloric intake should be approximately 1800 calories. Toddlers and preschoolers have similar nutritional requirements. There is an overall slight decrease in needed calories and fluids during the preschool period. DIF: Cognitive Level: Understanding REF: MCS: 539 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 15. A child age 4 1/2 years sometimes wakes her parents up at night screaming, thrashing, sweating, and apparently frightened, yet she is not aware of her parents presence when they check on her. She lies down and sleeps without any parental intervention. This is most likely what? a. Nightmare b. Sleep terror c. Sleep apnea d. Seizure activity ANS: B This is a description of a eslpeterror. T he lcdhiis orbs e ved during the seopi de and not disturbed unless there is a possibility of injury. A child who awakes from a nightmare is distressed. She is aware of and reassured by the parents presence. This is not tehcase with sl eep apnea. This behavior is not indicative of seizure activity. DIF: Cognitive Level: Analyzing REF: MCS: 539 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 16. During the preschool period, the emphasis of injury prevention should be placed on what? a. Limitation of physical activities b. Punishment for unsafe behaviors c. Constant vigilance and protection d. Teaching about safety and potential hazards ANS: D Education about safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Limitation of physical activities is not appropriate. Punishment may make children scared of trying new things. Constant vigilance and protection are not practical at this age because preschoolers are becoming more independent. DIF: Cognitive Level: Understanding REF: MCS: 539 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 17. The nurse is talking to the parent of a 5-year-old child who refuses to go to sleep at night. What intervention should the nurse suggest in helping the parent to cope with this sleep disturbance? a. Establish a consistent punishment if the child does not go to bed when told. b. Allow the child to fall asleep in a different room and then gently move the child to his or her bed. c. Establish limited rituals that signal readiness for bedtime. d. Allow the child to watch television until almost asleep. ANS: C An oaprirate in tervaenction for hild who resists going todbeis to establish l imitedlrsitua such as a bath or story that signal readiness for bed and consistently follow through with the ritual. Punishing the child will not alleviate the resistance problem and may only add to the frustration. Allowing the child to fall asleep in a different room and totwchate asleep are not recommended approaches to sleep resistance. DIF: Cognitive Level: Applying REF: MCS: 539 vilseion to f lla TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 18. At a seminar for parents with preschool-age children, the nurse has discussed anticipatory tasks during the preschool years. Which statement by a parent should indicate a correct understanding of the teaching? a. I should be worried if my 4-year-old child has an increase in sexual curiosity because this is a sign of sexual abuse. b. I should expect my 5-year-old to change from a tranquil child to an aggressive child when school starts. c. I should be concerned if my 4-year-old child starts telling exaggerated stories and has an imaginary playmate, since these could be signs of stress. d. I should expect my 3-year-old child to have a more stable appetite and an increase in food selections. ANS: D A 3-year-old child exhibits a more stable appetite than during the toddler years and is more willing to try different foods. A 4-year-old lcdhiis im aginative sanind tindulge leling tal talles and may have an imaginary playmate; these are normal findings, not signs of stress. Also a 4- year-old child has an increasing curiosity in sexuality, which is not a sign of child abuse. A 5- year-old child is usually tranquil, not aggressive like a 4-year-old child. DIF: Cognitive Level: Analyzing REF: MCS: 540 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is explaining average weight gain during the preschool years to a group of parents. Which average weight gain should the nurse suggest to the parents? a. 1 to 2 kg b. 2 to 3 kg c. 3 to 4 kg d. 4 to 5 kg ANS: B The average weight gain remains approximately 2 to 3 kg (4.56.5 lb) per year during the preschool period. DIF: Cognitive Level: Applying REF: MCS: 523 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 20. The nurse is planning to bring a preschool child a toy from the playroom. What toy is appropriate for this age group? a. Building blocks b. A 500-piece puzzle c. Paint by number picture d. Farm animals and equipment ANS: D The most characteristic and pervasive preschooler activity is imitative,aigminative, an d dramatic play. Farm animals and equipment would provide hours of self-expression. Building blocks are appropriate for older infants and toddlers. A 500-piece puzzle or a paint by number picture would be appropriate for a school-age child. DIF: Cognitive Level: Applying REF: MCS: 528 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 21. The nurse is conducting an assessment of fine motor development in a 3-year-old child. Which is the expected drawing skill for this age? a. Can draw a complete stick figure b. Holds the instrument with the fist c. Can copy a triangle and diamond d. Can copy a circle and imitate a cross ANS: D A 3-year-old child copies a circle and imitates a cross and vertical and horizontal lines. He or she holds the writing instrument with the rfisnrge ather than the fist.aAr 3-ye -old is not able to draw a complete stick gfiure but draws a circle, lfaatecriaaldfds eatures, and by age 5 or 6 years can draw several parts (head, arms, legs, body, and facial features). Copying a triangle and diamond are mastered sometime between ages 5 and 6 years. DIF: Cognitive Level: Applying REF: MCS: 523 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 22. What signals the resolution of the dOiepus or Electra complex? a. Learns sex differences b. Learns sexually appropriate behavior c. Identifies with the same-sex parent d. Has guilt over feelings toward the father or mother ANS: C The resolution of the Oedipus or Electra complex is identification with the same-sex parent. Learning sex differences and sexually appropriate behavior is a goal in further differentiation of oneself but does not signal the resolution of the Oedipus or Electra complex. Guilt over feelings toward the father or mother is seen as a stage in the complex, not the resolution. DIF: Cognitive Level: Understanding REF: MCS: 525 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 23. The nurse is explaining the preconventional stage of moral development to a group of nursing students. What characterizes this stage? a. Children in this stage focus on following the rules. b. Children in this stage live up to social expectations and roles. c. Children in this stage have a concrete sense of justice and fairness. d. Children in this stage have little, if any, concern for why something is wrong. ANS: D Young childrens development of moral judgment is at the most basic level in the preconventional stage. They have little, if any, concern for why something is wrong. Following the rules, living up to social expectations, and having a concrete sense of justice and fairness are characteristics in the conventional stage. DIF: Cognitive Level: Applying REF: MCS: 526 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Health Promotion and Maintenance 24. The nurse is teaching parents about instilling a positive body image for the preschool age. What statement made by the parents indicates the teaching is understood? a. We will make sure our child is praised about his or her looks. b. We will help our child compare his or her size with other children. c. We understand our child will have well-defined body boundaries. d. We will be sure our child understands about being little for his or her age. ANS: A Because these are formative years for both boys and girls, parents should make efforts to instill positive principles regarding body image. Children at this age are aware of the meaning of words such as pretty or ugly, and they reflect the opinions of others regarding their own appearance. Despite the advances in body image development, preschoolers have poorly defined body boundaries. By 5 years of age, children compare their size with that of their peers and can become conscious of being large or short, especially if others refer to them as so big or so little for their age. Parents should not suggest their child compare him- or herself with other children in regard to size, and parents should not focus on their childs size as being little. DIF: Cognitive Level: Applying REF: MCS: 526 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 25. The nurse has just given a subcutaneous injection to a preschool child, and the child asks for a Band-Aid over the site. Which action should the nurse implement? a. Place a Band-Aid over the site. b. Massage the injection site with an alcohol swab. c. Show the child there is no bleeding from the site. d. Explain that a Band-Aid is not needed after a subcutaneous injection. ANS: A Despite the advances in body image development, preschoolers have poorly defined body boundaries and little knowledge of their internal anatomy. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin (e.g., injections and surgery). They fear that all their blood and insides can leak out if the skin is broken. Therefore, preschoolers may believe it is critical to use bandages after an injury. The nurse should place a Band-Aid over the site. DIF: Cognitive Level: Applying REF: MCS: 527 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 26. Parents of a preschool lcdhit llethe nurse, O ur child seems to have many imaginary fears. What suggestion should the nurse give to the parents to help their child resolve the fears? a. Ignore the fears; they will go away. b. Explain to your child the fears are not real. c. Give your child some new toys to allay the fears. d. Help your child to resolve the fears through play activities. ANS: D Preschoolers are able to work through many of their unresolved fears, fantasies, and anxieties through play, especially if guided with appropriate play objects (e.g., dolls or puppets) that represent family members, health professionals, and other children. The fears should not be ignored because they may escalate. Preschoolers are not cognitively prepared for explanations about the fears. They gain security and comfort from familiar objects such as toys, dolls, or photographs of family members, so new toys should not be introduced. DIF: Cognitive Level: Applying REF: MCS: 527 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 27. A parent taking a preschool child to school on the first day asks the nurse, What do I do if my child wants me to stay? What is an appropriate response by the nurse? a. It is better if you do not stay. b. It is best to stay and participate in the activities. c. It is OK to stay part of the first day, but be inconspicuous. d. It would be better to have a good friend take your child to class the first day. ANS: C On the first day of preschool, in some instances, it is helpful for parents to remain for at least part of the first day until the child is comfortable. If parents stay, they should be available to the child but inconspicuous. It would not be appropriate not to stay, to have someone else take the child to school, or to stay and participate in activities. DIF: Cognitive Level: Applying REF: MCS: 533 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. What should the nurse suggest to parents of preschoolers about sensitive questions regarding sex? a. Distract your child from the topic. b. Offer complete factual information. c. Dismiss the topic until the child is older. d. Find out what your child knows or thinks. ANS: D Two rules govern answering sensitive questions about topics such as sex. The first is to find out what children know and think. By investigating the theories children have produced as a reasonable explanation, parents can not only give correct information but also help children understand why their explanation is inaccurate. Another reason for ascertaining what the child thinks before offering any information is to avoid giving an unasked for answer. The child should not be distracted from the topic. If parents offer too much information, the child will simply become bored or end the conversation with an irrelevant question. What matters is that parents are approachable and do not dismiss their childs inquiries. DIF: Cognitive Level: Applying REF: MCS: 533 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. What developmental achievements are demonstrated by a 4-year-old child? (Select tall tha apply.) a. Cares for self totally b. Throws a ball overhead c. Has a vocabulary of 1500 words d. Can skip and hop on alternate feet e. Tends to be selfish and impatient f. Commonly has an imaginary playmate ANS: B, C, E, F Developmental achievements for a 4-year-old child include throwing a ball overhead, having a vocabulary of 1500 words, tending to be selfish and impatient, and perhaps having an imaginary playmate. Caring for oneself totally and skipping and hopping on alternate feet are achievements normally seen in the 5-year-old age group. DIF: Cognitive Level: Analyzing REF: MCS: 529 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. Parenwts ar rieodr that their preschool -aged child is showing hyperaggressive behavior. What are signs of hyperaggresive behavior? (Select all that apply.) a. Disrespect b. Noncompliance c. Infrequent impulsivity d. Occasional temper tantrums e. Unprovoked physical attacks on other children ANS: A, B, E Hyperaggressive behavior in preschoolers is characterized by unprovoked tpahcykssical at on other children and adults, destruction of others property, frequent intense temper tantrums, extreme impulsivity, disrespect, and noncompliance. DIF: Cognitive Level: Analyzing REF: MCS: 535 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 3. The nurse understands that traits of gifted children include what? (Select all that apply.) a. Fair memory skills b. Limited sense of humor c. Perfectionism as a focus d. Inquisitive; always asking questions e. Displays intense feelings and emotion ANS: C, D, E Characteristics of gifted childrenliundce perfectionism as a focus; inquisitive, a wlay s asking questions; and displaying intense feelings and emotion. Memory skills are pronounced, and humor is exceptional. DIF: Cognitive Level: Understanding REF: MCS: 535 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. What are common causes of speech problems? (Select all that apply.) a. Autism b. Prematurity c. Hearing loss d. Developmental delay e. Overstimulated environment ANS: A, C, D Common causes of speech problems are hearing loss, developmental delay, autism, lack of environmental stimulation, and physical conditions that impede normal speech production. Prematurity and an overstimulated environment are not causes of speech problems. DIF: Cognitive Level: Analyzing REF: MCS: 536 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 5. What are sources of stress in preschoolers? (Select all that apply.) a. Shares possessions b. Damages or destroys objects c. May fear dogs or other animals d. Seems to be in perpetual motion e. May stutter or stumble over words ANS: B, C, D, E Sources of stress in preschoolers include damaging or destroying objects, fearing dogs or other animals, in perpetual motion, and may stutter or stumble over words. Guarding possessions, not sharing, is a source of stress. DIF: Cognitive Level: Analyzing REF: MCS: 537 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 6. What is the reason pedestrian motor vehicle injuries increase in the preschool age? (Select all that apply.) a. Riding tricycles b. Running after balls c. Playing in the street d. Crossing streets at the crosswalk e. Crossing streets with an adult ANS: A, B, C Pedestrian motor lveehinicjuries increase because of activities such as playing in the street, riding tricycles, running after balls, and forgettingysarfet egulations when crossing streets. Crossing streets at the crosswalk or with an adult are safety measures. DIF: Cognitive Level: Analyzing REF: MCS: 539 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 7. Parents ask the nurse, Should we be concerned our preschooler has an imaginary friend, and how should we react? Which responses should the nurse give to the parents? (Select all that apply.) a. The imaginary playmate is a sign of health. b. You can acknowledge the presence of the imaginary companion. c. It is normal for a preschool-aged child to have an imaginary friend. d. If your child wants a place setting at the table for the child, it is best to refuse. e. It is OK to allow the child to blame the imaginary playmate to avoid punishment. ANS: A, B, C Parents should be reassured that the childs fantasy is a sign of health that helps differentiate between make-believe and reality. Parents can acknowledge the presence of the imaginary companion by calling him or her by name and even agreeing to simple requests such as setting an extra place at the table, but they should not allow the child to use the playmate to avoid punishment or responsibility. DIF: Cognitive Level: Applying REF: MCS: 526 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is teaching parents of a 3-year-old child about gross motor developmental milestones. What milestones should the nurse include in the teaching session? (Select all that apply.) a. Rides a tricycle b. Catches a ball reliably c. Jumps off the bottom step d. Stands on one foot for a few seconds e. Walks downstairs using alternate footing ANS: A, C, D The gross motor lmesitones of a 3-year-old lcdhiinc lude riding a tricycle, jumping off the bottom step, and standing on one foot for a few seconds. Catching a ball reliably and walking downstairs using alternate footing are gross motor milestones seen at the age of 4 years. DIF: Cognitive Level: Applying REF: MCS: 523 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is teaching parents of a 4-year-old child about fine motor developmental milestones. What milestones should the nurse include in the teaching session? (Select all that apply.) a. Can lace shoes b. Uses scissors successfully c. Builds a tower of nine or 10 cubes d. Builds a bridge with three cubes e. Adeptly places small pellets in a narrow-necked bottle ANS: C, D, E The fine motor lmesitones of a 4-year-old child include building a tower of nine or 10 cubes, building a bridge with three cubes, and adeptly placing small pellets in a narrow-necked bottle. Lacing shoes and using scissors successfully are fine motor milestones seen at the age of 5 years. DIF: Cognitive Level: Applying REF: MCS: 529 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. The nurse is teaching epnarts of a 3-year-old child about language developmental milestones. What milestones should the nurse include in the teaching session? (Select all that apply.) a. Asks many questions b. Names one or more colors c. Repeats sentence of six syllables d. Uses primarily telegraphic speech e. Has a vocabulary of 1500 words or more ANS: A, C, D The language milestones of a 3-year-old child include asking many questions, repeating a sentence of six syllables, and using primarily telegraphic speech. Naming one or more colors and having a vocabulary of 1500 words or more footing are language milestones seen at the age of 4 years. DIF: Cognitive Level: Applying REF: MCS: 529 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 11. The nurse is teaching parents of a 4-year-old child about socialization developmental milestones. What milestones should the nurse include in the teaching session? (Select all that apply.) a. Very independent b. Has mood swings c. Has better manners d. Eager to do things right e. Tends to be selfish and impatient ANS: A, B, E The socialization milestones of a 4-year-old child include being very independent, having moods swings, and tending to be selfish and impatient. Having better manners and being eager to do things right are socialization milestones seen at the age of 5 years. Chapter 14.Health Problems of Early Childhood MULTIPLE CHOICE 1. A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action? a. Reassure the father that Visine is harmless. b. Direct him to seek immediate medical treatment. c. Recommend inducing vomiting with ipecac. d. Advise him to dilute Visine by giving his daughter several glasses of water to drink. ANS: B Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary. Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk. DIF: Cognitive Level: Applying REF: MCS: 548 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n. tTeghreitnyurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product? a. Tinnitus b. Disorientation c. Stupor, lethargy, and coma d. Edema of the lips, tongue, and pharynx ANS: D Edema of the lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system. DIF: Cognitive Level: Analyzing REF: MCS: 546 TOP: Nursing Process: Assessment :MCSC ielnt Needs: Physiological Integrity 3. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is what? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia ANS: D Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic consequence of hydrocarbon ingestion. DIF: Cognitive Level: Applying REF: MCS: 546 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. What is a clinical manifestation of acetaminophen poisoning? a. Hyperpyrexia b. Hepatic involvement c. Severe burning pain in stomach d. Drooling and inability to clear secretions ANS: B Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach and does not pose an airway threat. DIF: Cognitive Level: Understanding REF: MCS: 546 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 5. An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner? a. Giving half of the solution and then repeating the other half in 1 hour b. Mixing with a flavorful beverage in an opaque container with a straw c. Serving it in a clear plastic cup so the child can see how much has been drunk d. Administering it through a nasogastric tube because the child will not drink it because of the taste ANS: B Although activated charcoal can be mixed with a flavorful sugar-free beverage, it will lbaeckb and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being distasteful. The ability to see the charcoal solution may affect the childs desire to drink the solution. The child should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be used only in children who cannot be cooperative or those without a gag reflex. DIF: Cognitive Level: Applying REF: MCS: 547 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. What is a significant secondary prevention nursing activity for lead poisoning? a. Chelation therapy b. Screening children for blood lead levels c. Removing lead-based paint from older homes d. Questioning parents about ethnic remedies containing lead ANS: B Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning epnarts about iecthrnemedies containing lead is part of the assessment to determine the potential source of lead. DIF: Cognitive Level: Applying REF: MCS: 551 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. What is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead poisoning? a. Maintain bed rest. b. Maintain isolation precautions. c. Keep an accurate record of intake and output. d. Institute measures to prevent skeletal fracture. ANS: C The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. Chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result from high levels of lead. DIF: Cognitive Level: Applying REF: MCS: 555 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 8. What is the tmcoosmmon form of child maltreatment? a. Sexual abuse b. Child neglect c. Physical abuse d. Emotional abuse ANS: B Child neglect, which is characterized by the failure to provide for the childs basic needs, is the most common form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common as neglect. DIF: Cognitive Level: Applying REF: MCS: 556 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). What is an important consideration in the care of this child? a. Monitoring the parents whenever they are with the child b. Reassuring the parents that the cause of the disorder will be found c. Teaching the parents how to obtain necessary specimens d. Supporting the parents as they cope with diagnosis of a chronic illness ANS: A MSBP refers to an illness that one person fabricates or induces in another. The child must be continuously observed for development of symptoms to determine the cause. MSBP is caused by an individual harming the child for the purpose of gaining attention. Nursing staff should obtain all specimens for analyzing. This minimizes the possibility of the abuser contaminating the sample. The child must be supported through the diagnosis of MSBP. The abuser must be identified and the child protected from that individual. DIF: Cognitive Level: Applying REF: MCS: 558 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 10. When only one child is abused in a family, the abuse is usually a result of what? a. The child is the firstborn. b. The child is the same gender as the abusing parent. c. The parent abuses the child to avoid showing favoritism. d. The parent is unable to deal with the childs behavioral style. ANS: D The child unintentionally contributes to the abuse. The fit or compatibility between the childs temperament and the parents ability to deal with that behavior style is an important predictor. Birth order and gender can contribute to abuse, but there is not a specific birth order or gender relationship that aistiivnedic of abuse.iBnge the firstborn or the same gender as the abuser tis no linked to child abuse. Avoidance of favoritism is not usually a cause of abuse. DIF: Cognitive Level: Understanding REF: MCS: 565 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity 11. The parents of a 7-year-old boy tell the nurse that lately he has been cruel to their family pets and actually caused physical harm. The nurses recommendation should be based on remembering what? a. This is an expected behavior at this age. b. This is a warning sign of a serious problem. c. This is harmless venting of anger and frustration. d. This is common in children who are physically abused. ANS: B Cruelty to family pets is not an expected behavior. Hurting animals can be one of the earliest symptoms of a conduct disorder. Abusing animals does not dissipate violent emotions; rather, the acts may fuel the abusive behaviors. Referral for evaluation is essential. This behavior may be seen in emotional abuse or neglect, not physical abuse DIF: Cognitive Level: Applying REF: MCS: 562 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 12. A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect? a. Unintentional injury b. Shaken baby syndrome c. Congenital neurologic problem d. Sudden infant death syndrome (SIDS) ANS: B Shaken baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. With unintentional injuries, external signs are usually present. Congenital neurologic problems would usually have signs of abnormal neurologic anatomy. SIDS does not usually have identifiable injuries. DIF: Cognitive Level: Analyzing REF: MCS: 557 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity 13. What statement is correct about young children who report sexual abuse? a. They may exhibit various behavioral manifestations. b. In more than half the cases, the child has fabricated the story. c. Their stories should not be believed unless other evidence is apparent. d. They should be able to retell the story the same way to another person. ANS: A Victims of sexual abuse have no typical profile. The child may exhibit various behavioral manifestations, none of which is diagnostic for sexual abuse. When children report potentially sexually abusive experiences, their reports need to be taken seriously. Other children in the household also need to be evaluated. In children who are sexually abused, it is often difficult to identify other evidence. In one study, approximately 96% of children who were sexually abused had normal genital and anal findings. The ability to retell the story is partly dependent on the childs cognitive level. Children who repeatedly tell identical stories may have been coached. DIF: Cognitive Level: Understanding REF: MCS: 559 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 14. What is probably the most important criterion on which to base the decision to report suspected child abuse? a. Inappropriate response of child b. Inappropriate parental concern for the degree of injury c. Absence of parents for questioning about childs injuries d. Incompatibility between the history and injury observed ANS: D Conflicting stories about the accident are the most indicative red flags of abuse. The child or caregiver may have an inappropriate response, but this is subjective. Parents should be questioned at some point during the investigation. DIF: Cognitive Level: Understanding REF: MCS: 560 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 15. The nurse is caring for a child with suspected ingestion of some type of poison. What action should the nurse take next after initiating cardiopulmonary resuscitation (CPR)? a. Empty the mouth of pills, plants, or other material. b. Question the victim and witness. c. Place the child in a side-lying position. d. Call poison control. ANS: A Emptying the mouth of any leftover pills, plants,hoer ot r ingested material is the xnet step a fter assessment and initiation of CPR if needed. Questioning the victim and witnesses, calling poison control, and placing the child in a side-lying position are follow-up steps. DIF: Cognitive Level: Applying REF: MCS: 548 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 16. The nurse is teaching parents of a preschool child strategies to implement when the child delays going to bed. What strategy should the nurse recommend? a. Use consistent bedtime rituals. b. Give in to attention-seeking behavior. c. Take the child into the parents bed for an hour. d. Allow the child to stay up past the decided bedtime. ANS: A For children who delay going to bed, a recommended approach involves a consistent bedtime ritual and emphasizing the normalcy of this type of behavior in young children. Parents should ignore attention-seeking behavior, and the child should not be taken into the parents bed or allowed to stay up past a reasonable hour. DIF: Cognitive Level: Applying REF: MCS: 543 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed? a. Carnitine (Carnitor) b. Fomepizole (Antizol) c. Deferoxamine (Desferal) d. N-acetylcysteine (Mucomyst) ANS: D The antidote for acetaminophen (Tylenol) poisoning is N-acetylcysteine (Mucomyst). Carnitine (Carnitor) is an antidote for valproic acid (Depakote), fomepizole (Antizol) is the taindote f or methanol poisoning, and deferoxamine (Desferal) is the antidote for iron poisoning. DIF: Cognitive Level: Applying REF: MCS: 547 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 18. A child with diazepam (Valium) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed? a. Succimer (Chemet) b. EDTA (Versenate) c. Flumazenil (Romazicon) d. Octreotide acetate (Sandostatin) ANS: C The antidote for diazepam (Valium) poisoning is flumazenil (Romazicon). Succimer (Chemet) and EDTA (Versenate) are antidotes for heavy metal poisoning. Octreotide acetate (Sandostatin) is an antidote for sulfonylurea poisoning. DIF: Cognitive Level: Applying REF: MCS: 549 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 19. A child is admitted to the hospital with lesions on his abdomen thaa burns. What should accurate documentation by the nurse include? ppear like cigarette a. Two unhealed lesions are on the childs abdomen. b. Two round 4-mm lesions are on the childs lower abdomen. c. Two round symmetrical lesions are on the childs lower abdomen. d. Two round lesions on the childs abdomen that appear to be cigarette burns. ANS: B Burn documentation should include the location, pattern, demarcation lines, and presence of eschar or blisters. The option that includes the size of the lesions is the most accurate. DIF: Cognitive Level: Applying REF: MCS: 561 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Physiological Integrity 20. What do inflicted immersion burns often appear as? a. Partial-thickness, asymmetrical burns b. Splash pattern burns on hands or feet c. Any splash burn with dry linear marks d. Sharply demarcated, symmetrical burns ANS: D Immersion burns are sharply demarcated symmetrical burns. Asymmetrical burns and splash burns are often accidental. DIF: Cognitive Level: Understanding REF: MCS: 562 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 21. A child has been admitted to the hospital with a blood lead level of 72 mcg/dL. What treatment should the nurse anticipate? a. Referral to social services b. Initiation of chelation therapy c. Follow-up testing within 1 month d. Aggressive environmental intervention ANS: B Severe lead toxicity (lead level ?5=70 mcg/dL) requires immediate inpatient chelation treatment. Referral to social service and follow-up in 1 month are prescribed for lead levels of 15 to 19 mcg/dL. Aggressive environmental intervention would be initiated after chelation treatments. DIF: Cognitive Level: Applying REF: MCS: 553 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 22. The nurse is teaching parents of preschoolers about plants that are poisonous. What plant should the nurse include in the teaching session? a. Azalea b. Begonia c. Boston fern d. Asparagus fern ANS: A All parts of the azalea are poisonous. Begonias, Boston ferns, and asparagus ferns are nonpoisonous plants. DIF: Cognitive Level: Applying REF: MCS: 545 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 23. A child with corrosive poisoning is being admitted to the emergency department. What clinical manifestation does the nurse expect to asscsheislsd?on thi a. Nausea and vomiting b. Alterations in sensorium, such as lethargy c. Severe burning pain in the mouth, throat, and stomach d. Respiratory symptoms of acute pulmonary involvement ANS: C Severe burning pain in hth,ethmrooautt, and stomach is a clinical manifestation of corrosive poisoning. Nausea and vomiting; alterations in sensorium, such as lethargy; and respiratory symptoms of acute pulmonary involvement are clinical manifestations of hydrocarbon poisoning. DIF: Cognitive Level: Applying REF: MCS: 546 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 24. A child with acetylsalicylic acid (aspirin) poisoning is being admitted to the emergency department. What early clinical manifestation does the nurse expect to assess on this child? a. Hematemesis b. Hematochezia c. Hyperglycemia d. Hyperventilation ANS: D An early clinical manifestation of acetylsalicylic acid (aspirin) poisoning is hyperventilation. Hematemesis, hematochezia, and hyperglycemia are clinical manifestations of iron poisoning. DIF: Cognitive Level: Applying REF: MCS: 546 TOP: NursoicnegssP:rAssessmen t MSC: Client Needs: Physiological Integrity 25. A child with cyanide poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed for the child? a. Atropine b. Glucagon c. Amyl nitrate d. Naloxone (Narcan) ANS: C Amyl nitrate is the antidote for cyanide poisoning. Atropine is an antidote for organophosphate poisoning, glucagon is an antidote for a beta-blocker poisoning, and naloxone (Narcan) is an antidote for an opioid poisoning. DIF: Cognitive Level: Applying REF: MCS: 549 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is teaching parents of preschool children consequences of inadequate sleep. What should the nurse include in the teaching session? (Select all that apply.) a. Behavior changes b. Increased appetite c. Difficulty concentrating d. Poor control of emotions e. Impaired learning ability ANS: A, C, D, E Consequences of inadequate sleep include daytime tiredness, behavior changes, hyperactivity, difficulty concentrating, impaired learning ability, poor control of emotions and impulses, and strain on family relationships. Increased appetite is not a consequence of inadequate sleep. DIF: Cognitive Level: Applying REF: MCS: 543 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 2. The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for? (Select all that apply.) a. Diarrhea b. Vomiting c. Fluid retention d. Intestinal obstruction ANS: B, D Potential complications from the use of activated charcoal include vomiting and possible aspiration, constipation, and intestinal obstruction. Diarrhea and fluid retention are not potential complications of activated charcoal administration. DIF: Cognitive Level: Applying REF: MCS: 546 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 3. What can the nurse suggest toifliaems to reduce blood lead levels? (Select all that apply.) a. Do not store food in open cans. b. Ensure the child eats regular meals. c. Mix formula with hot water from the tap. d. Vacuum hard-surfaced floors and window wells. e. Wash and dry the childs hands and face frequently. ANS: A, B, E To reduce blood lead levels, the family should ensure the child eats regular meals because more lead is absorbed on an empty stomach. The childs hands and face should be washed and dried frequently, especially before eating. Food should not be stored in open cans, particularly if cans are imported. Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. Hot water should not be used to mix formula. Hard-surfaced floors or window sills or wells should not be vacuumed because this spreads dust. DIF: Cognitive Level: Applying REF: MCS: 554 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. What are symptoms of abusive head trauma (AHT) in the more severe form that may be present? (Select all that apply.) a. Seizures b. Posturing c. Tachypnea d. Tachycardia e. Altered level of consciousness ANS: A, B, E In more severe forms, presenting symptoms of abusive head trauma may include seizures, posturing, alterations in level of consciousness, apnea, bradycardia, or death. DIF: Cognitive Level: Understanding REF: MCS: 557 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 5. The nurse is teaching parents of preschool-aged children strategies to prevent lseaxbuuas e. What should the nurse include in the teaching session? (Select all that apply.) a. Back up a childs right to say no. b. Dont take what your child says too seriously. c. Take a second look at signals of potential danger. d. Dont be too detailed about examples of sexual assault. e. Remind children that even nice people sometimes do mean things. ANS: A, C, E To provide protection and preparation from sexual abuse, parents should back up a childs right to say no, take a second look at signals of potential danger, and remind children that even nice people sometimes do mean things. Parents should take what children say seriously and they should give specific definitions and examples of sexual assault. DIF: Cognitive Level: Applying REF: MCS: 559 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. A parent asks the nurse about the characteristics of a nightmare. What response should the nurse give to the parent? (Select all that apply.) a. Nightmares are scary dreams. b. The child can describe the nightmare. c. The child is reassured by your presence. d. Nightmares occur usually 1 to 4 hours after falling asleep. e. Nightmares take place during nonrapid eye movement sleep ANS: A, B, C Nightmares are scary dreams, the child can describe the nightmare, acnhdildthies reassured by a parents presence. Sleep terrors occur usually 1 to 4 hours after falling asleep, but nightmares occur in the second half of sleep. Sleep terrors occur during nonrapid eye movement sleep, but nightmares occur during rapid eye movement sleep. DIF: Cognitive Level: Applying REF: MCS: 544 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 7. A parent asks the nurse about the characteristics of raosrl.eWep ter nurse give to the parent? (Select all that apply.) a. The child screams during the sleep terror. b. Return to sleep is delayed because of persistent fear. c. The night terror occurs during the second half of night. d. The child has no memory of the dream with a sleep terror. e. The child is not aware of anothers presence during a sleep terror. ANS: A, D, E hat response should the During sleep terrors, the child screams and has no memory of the dream. The child is not aware of anothers presence during a sleep terror. Return to sleep is usually rapid with a sleep terror, but it is delayed with a nightmare. The sleep toercrcourrs us ually within 1 to 4 hours of sleep, but nightmares occur during the second half of night. DIF: Cognitive Level: Applying REF: MCS: 544 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. What are classified as hydrocarbon poisons? (Select all that apply.) a. Bleach b. Gasoline c. Turpentine d. Lighter fluid e. Oven cleaners ANS: B, C, D Gasoline, turpentine, and lighter fluid are classified as hydrocarbon poisons. Bleach and oven cleaners are classified as corrosive poisons. Chapter 15.Health Promotion of the School-Age Child and Family MULTIPLE CHOICE 1. What statement accurately describes physical development during the school-age years? a. The childs weight almost triples. b. Muscles become functionally mature. c. Boys and girls double strength and physical capabilities. d. Fat gradually increases, which contributes to childrens heavier appearance. ANS: C Boys and girls double both strength and physical capabilities. Their consistent refinement in coordination increases their poise and skill. In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 5 cm/yr and gain 3 kg/yr. Their weight will almost double. Although the strength increases, muscles are still functionally immature when compared with those of adolescents. This age group is more easily injured by overuse. Children take on a slimmer look with longer legs in middle childhood. DIF: Cognitive Level: Understanding REF: MCS: 569 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. The parents of 9-year-old twin children tell the nurse, They have filled up their bedroom with collections of rocks, shells, stamps, and bird nests. The nurse should recognize that this is which? a. Indicative of giftedness b. Indicative of typical twin behavior c. Characteristic of cognitive development at this age d. Characteristic of psychosocial development at this age ANS: C Classification skills involve the ability to group objects according to the attributes they have in common. School-age children can place things in a sensible and logical order, group and sort, and hold a concept in nthdeiwr hmilie they make decisions based on that concept. Individuals who are not twins engage in classification at this age. Psychosocial behavior at this age is described according to Eriksons stage of industry versus inferiority. DIF: Cognitive Level: Analyzing REF: MCS: 573 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. What statement acchtaerrizes moral de velopment in the older school-age child? a. Rule violations are viewed in an isolated context. b. Judgments and rules become more absolute and authoritarian. c. The child remembers the rules but cannot understand the reasons behind them. d. The child is able to judge an act by the intentions that prompted it rather than just by the consequences. ANS: D Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rule violation is likely to be viewed in relation to the total context in which it appears. Rules and judgments become less absolute and authoritarian. The situation and the morality of the rule itself influence reactions. DIF: Cognitive Level: Understanding REF: MCS: 575 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. An 8-year-old girl tells the nurse that she has cancer because God is punishing her for being bad. What should the nurse interpret this as? a. A common belief at this age b. Indicative of excessive family pressure c. Faith that forms the basis for most religions d. Suggestive of a failure to develop a conscience ANS: A Children at this age may view illness or injury as a punishment for a real or imagined misbehavior. School-age children expect to be punished and tend to choose a punishment that they think tfsi the crime. This is a common belief and not lraeted t oievxecfeasms ily pressure. Many faiths do not include a God that causes cancer in response for bad behavior. This statement reflects the childs belief in what is right and wrong. DIF: Cognitive Level: Analyzing REF: MCS: 575 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. What is the role of the peer group in the life of school-age children? a. Decreases their need to learn appropriate sex roles b. Gives them an opportunity to learn dominance and hostility c. Allows them to remain dependent on their parents for a longer time d. Provides them with security as they gain independence from their parents ANS: D Peer group identification is an important factor in gaining independence from parents. Through peer relationships, children learn ways to deal with dominance and hostility. They also learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. A childs concept of appropriate sex roles is influenced by relationships with peers. DIF: Cognitive Level: Understanding REF: MCS: 576 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Health Promotion and Maintenance 6. What is descriptive of the social development of school-age children? a. Identification with peers is minimum. b. Children frequently have best friends. c. Boys and girls play equally with each other. d. Peer approval is not yet an influence for the child to conform. ANS: B Identification with peers is a strong influence in childrens gaining independence from parents. Interaction among peers leads to the formation of close friendships with same-sex peersbest friends. Daily relationships with age mates in the school setting provide important social interactions for school-age children. During the later school years, groups are composed predominantly of children of the same sex. Conforming to the rules of the peer group provides children with a sense of security and relieves them of the responsibility of making decisions. DIF: Cognitive Level: Understanding REF: MCS: 576 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 7. What statement best describes the relationshipgsechcool-a hildren have with athmeilriefs? a. Ready to reject parental controls b. Desire to spend equal time with family and peers c. Need and want restrictions placed on their behavior by the family d. Peer group replaces the family as the primary influence in setting standards of behavior and rules ANS: C School-age children need and want restrictions placed on their behavior, and they are not prepared to tchopaell wi the problems of their expanding environment. Although increased independence is the goal of middle childhood, they feel more secure knowing that an authority figure can implement controls and restriction. In the middle school years, children prefer peer group activities to family activities and want to spend more time in the company of peers. Family values usually take precedence over peer value systems. DIF: Cognitive Level: Understanding REF: MCS: 578 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. A parent asks about whether a 7-year-old child is able to care for a dog. Based on the childs age, what does the nurse suggest? a. Caring for an animal requires more maturity than the average 7-year-old possesses. b. This will help the parent identify the childs weaknesses. c. A dog can help the child develop confidence and emotional health. d. Cats are better pets for ascgheool- children. ANS: C Pets have been ovbedsetro i nfluence a childs self-esteem. They can have a positive effect on physical and emotional health and can teach children the importance of nurturing and nonverbal communication. Most 7-year-old children are capable of caring for a pet with supervision. Caring for a pet should be a positive experience. It should not be used to identify weaknesses. The pet chosen does not matter as much as the childs being responsible for a pet. DIF: Cognitive Level: Applying REF: MCS: 579 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. The school nurse has been asked to begin teaching sex education in the fifth grade. What should the nurse recognize? a. Questions need to be discouraged in this setting. b. Most children in the fifth grade are too young for sex education. c. Sexuality is presented as a normal part of growth and development. d. Correct terminology should be reserved for children who are older. ANS: C When sexual information is presented to school-age children, sex should be treated as a normal part of growth and development. They should be encouraged to ask questions. At 10 to 11 years old, fifth graders are not too young to speak about physiologic changes in their bodies. Preadolescents need precise and concrete information. DIF: Cognitive Level: Applying REF: MCS: 580 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. What is descriptive of the play of school-age children? a. They like to invent games, making up the rules as they go. b. Individuality in play is better tolerated than at earlier ages. c. Knowing the rules of a game gives an important sense of belonging. d. Team play helps children learn the universal importance of competition and winning. ANS: C Play involves increased physical skill, intellectual ability, anntadsyfa. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States but not in all cultures. DIF: Cognitive Level: Understanding REF: MCS: 581 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. The school nurse is providing guidance to families of children who are entering elementary school. What is essential information to include? a. Meet with teachers only at scheduled conferences. b. Encourage growth of a sense of responsibility in children. c. Provide tutoring for children to ensure mastery of material. d. Homework should be done as soon as child comes home from school. ANS: B By being responsible for school work, children learn to keep promises, meet deadlines, and succeed in their jobs as adults. Parents should meet with the teachers at the beginning of the school year, for scheduled conferences, and whenever information about the child or parental concerns needs to be shared. Tutoring should be provided only in special circumstances in elementary school, such as in response to prolonged absence. The parent should not dictate the study time but should establish guidelines to ensure that homework is done. DIF: Cognitive Level: Applying REF: MCS: 585 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 12. What is characteristic of dishonest behavior in children ages 8 to 10 years? a. Cheating during games is now more common. b. Stealing can occur because their sense of property rights is limited. c. Lying is used to meet expectations set by others that they have been unable to attain. d. Dishonesty results from the inability to distinguish between fact and fantasy. ANS: C Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems. In this age group, children are able to distinguish between fact and fantasy. DIF: Cognitive Level: Understanding REF: MCS: 586 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 13. A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says she is completing her school work satisfactorily but lately has been somewhat aggressive and stubborn in the classroom. The school nurse should recognize this as which? a. Signs of stress b. Developmental delay c. Lack of adjustment to school environment d. Physical problem that needs medical intervention ANS: A Signs of stress include stomach pains or chheea,dsal eep opr blems, bedwetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to earlier behaviors. The child is completing school work satisfactorily; any developmental delay would have been diagnosed earlier. The teacher reports that this is a odempathrteure fr childs normal behavior. Adjustment issues would most likely be evident soon after a change. Medical intervention is not immediately required. Recognizing that this constellation of symptoms can indicate stress, the nurse should help the child identify sources of stress and how to use stress reduction techniques. The parents are involved in the evaluation process. DIF: Cognitive Level: Analyzing REF: MCS: 588 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 14. What statement best describes fear inlschoo -age children? a. Increasing concerns about bodily safety overwhelm them. b. They should be encouraged to hide their fears to prevent ridicule by peers. c. Most of the new fears that trouble them are related to school and family. d. Children with numerous fears need continuous protective behavior by parents to eliminate these fears. ANS: C During the school-age years, children experience a wide variety of fears, but new fears related predominantly to school and family bother children during this time. Parents and other persons involved with children should discuss childrens fear with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding the fears does not end them and may lead to phobias. DIF: Cognitive Level: Analyzing REF: MCS: 589 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. A school-age child has begun to sleepwalk. What does the nurse advise the parents to perform? a. Wake the child and help determine what is wrong. b. Leave the child alone unless he or she is in danger of harming him- or herself or others. c. Arrange for psychologic evaluation to identify the cause of stress. d. Keep the child awake later in the evening to ensure sufficient tiredness for a full night of sleep. ANS: B Sleepwalking is usually self-limiting and requires no treatment. The child usually moves about restlessly and then returns to bed. Usually the actions are repetitive and clumsy. The child should not be awakened unless in danger. If there is a need to awaken the child, it should be done by calling the childs name to gradually bring to a state of alertness. Some children, who are usually well behaved and tend to repress feelings, may sleepwalk because of strong emotions. These children usually respond to relaxation techniques before bedtime. If a child is overly fatigued, sleepwalking can increase. DIF: Cognitive Level: Applying REF: MCS: 593 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 1In6t.eTgrhietyschool nurse is discussing after-school sports participation with parents of children age 10 years. The nurses presentation includes which important consideration? a. Teams should be gender specific. b. Organized sports are not appropriate at this age. c. Competition is detrimental to the establishment of a positive self-image. d. Sports participation is encouraged if the type of sport is appropriate to the childs abilities. ANS: D Virtually every child is suited for some type of sport. The child should be matched to the type of sport appropriate to his or her abilities and physical and emotional makeup. At this age, girls and boys have the same basic structure and similar responses to exercise and training. After puberty, teams should be gender specific because of the increased muscle mass in boys. gOarnized spor ts help children learn teamwork and skill acquisition. The emphasis should be on playing and learning. Children do enjoy appropriate levels of competition. DIF: Cognitive Level: Applying REF: MCS: 594 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. What do nursing interventions to promote health during middle childhood include? a. Stress the need for increased calorie intake to meet increased demands. b. Instruct parents to defer questions about sex until the child reaches adolescence. c. Advise parents that the child will need increasing amounts of rest toward the end of this period. d. Educate parents about the need for good dental hygiene because these are the years in which permanent teeth erupt. ANS: D The permanent teeth erupt during the school-age years. Good dental hygiene and regular attention to dental caries are vital parts of health supervision during this period. Caloric needs are decreased in relation to body size for this age group. Balanced nutrition is essential to promote growth. Questions about sex should be addressed honestly as the child asks questions. The child usually no longer needs a nap, but most require approximately 11 hours of sleep each night at age 5 years and 9 hours at age 12 years. DIF: Cognitive Level: Applying REF: MCS: 597 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 18. The school nurse needs to obtain authorization for a child who requires medications while at school. From whom does the nurse obtain the authorization? a. The parents b. The pharmacist c. The school administrator d. The prescribing practitioner ANS: A A child who requires medication during the school day requires written authorization from the parent or guardian. Most schools also require that the medication be in the original container appropriately labeled by the pharmacist or physician. Some schools allow children to receive over-the-counter medications with epnartal pe rmission. The pharmacist may be asked to appropriately label the medication for use at the school, but authorization is not required. The school administration should have a policy in place that facilitates the administration of medications for children who need them. The prescribing practitioner is responsible for ensuring that the medication is appropriate for the child. Because the child is a minor, parental consent is required. DIF: Cognitive Level: Applying REF: MCS: 600 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19. What is an important consideration in preventing injuries during middle childhood? a. Achieving social acceptance is a primary objective. b. The incidence of injuries in girls is significantly higher than it is in boys. c. Injuries from burns are the highest at this age because of fascination with fire. d. Lack of muscular coordination and control results in an increased incidence of injuries. ANS: A School-age children often participate in dangerous activities in an attempt to prove themselves worthy of acceptance. The incidence of injury during middle childhood is significantly higher in boys compared with girls. Motor ivcelh e collisions are the most common cause of severe injuries in children. Children have increasing muscular coordination. Children who are risk takers may have inadequate self-regulatory behavior. DIF: Cognitive Level: Analyzing REF: MCS: 600 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 20. When teaching injury prevention during the school-age years, what should the nurse include? a. Teach children about the need to fear strangers. b. Teach basic rules of water safety. c. Avoid letting children cook in microwave ovens. d. Caution children against engaging in competitive sports. ANS: B Water safety instruction is an important component of injury prevention at this age. The child should be taught to swim, select safe and supervised places to swim, swim with a companion, check sufficient water depth for diving, and use an approved flotation device. Teach stranger safety, not fear of strangers. This includes telling the child not to go with strangers, not to wear personalized clothing in public places, to tell parents if anyone makes child feel uncomfortable, and to say no in uncomfortable situations. Teach the child safe cooking. Caution against engaging in dangerous sports such as jumping on trampolines. DIF: Cognitive Level: Applying REF: MCS: 601 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Health Promotion and Maintenance 21. What is an important consideration for the school nurse who is planning a class on bicycle safety? a. Most bicycle injuries involve collision with an automobile. b. Head injuries are the major causes of bicycle-related fatalities. c. Children should wear a bicycle helmet if they ride on paved streets. d. Children should not ride double unless the bicycle has an extra large seat. ANS: B The most important aspect of bicycle safety is to encourage the rider toruostecatipve helmet. Head injuries are the major cause of bicycle-related tfalities. A lthough motor vehicle collisions do cause injuries to bicyclists, most injuries result from falls. The child should always wear a properly fitted helmet approved by the U.S. Consumer Product Safety Commission. Children should not ride double unless it is a tandem bike (built for two). DIF: Cognitive Level: Analyzing REF: MCS: 603 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. The American Academy of rPiecdsi(aAt AP) r ecommends that children younger than the age of 16 years be prohibited from participating in what? a. Skateboarding b. Snowmobiling c. Trampoline use d. Horseback riding ANS: B The AAP views the use of snowmobiles and all-terrain vehicles as major health hazards for children. This group opposes the use of these vehicles by children younger than 16 years of age. The AAP recommends that children younger than the age of 10 years not use skateboards without parental supervision. Protective gear is always suggested. Trampoline use has increased along with injuries. Adults should supervise use. Horseback riding injuries are also a source of concern. Parents should determine the instructors safety record with students. DIF: Cognitive Level: Understanding REF: MCS: 604 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 23. The nurse is developing a teaching pamphlet for parents of school-age children. What anticipatory guidelines should the nurse include in the pamphlet? a. At age 6 years, parents should be certain that the child is reading independently with books provided by school. b. At age 8 years, parents should expect a decrease in involvement with peers and outside activities. c. At age 10 years, parents should expect a decrease in admiration of the parents with little interest in parentchild activities. d. At age 12 years, parents should be certain that the childs sex education is adequate with accurate information. ANS: D A 12-year-old child should have been introduced to sex education, and parents should be certain that the information is adequate and accurate and that the child is not embarrassed to talk about sexual feelings or other aspects of sex education. At age 6 years, a child does not need to be reading independently and usually still needs help with reading and enjoys being read to. At 8 years of age, parents should expect their child to show increased involvement with peers and outside activities and should encourage this behavior. A 10-year-old child exhibits increased feelings of admiration of parents, especially fathers, and parentchild activities should be encouraged. DIF: Cognitive Level: Applying REF: MCS: 606 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 24. The nurse is teaching a class on nutrition to a group of parents of 10- and 11-year-old children. What statement by one of the parents indicates a correct understanding of the teaching? a. My child does not need to eat a variety of foods, just his favorite food groups. b. My child can add salt and sugar to foods to make them taste better. c. I will serve foods that are low in saturated fat and cholesterol. d. I will continue to serve red meat three times per week for extra iron. ANS: C School-age children should be eating foods that are low in saturated fat and cholesterol to prevent long-term consequences. The childs diet should include a variety of foods, include moderate amounts of extra salt and sugar, emphasize consumption of lean protein (chicken and pork), and limit red meat. DIF: Cognitive Level: Applying REF: MCS: 592 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n5t.eAgrimtyale school-age student asks the school nurse, How much with my height increase in a year? The nurse should give which response? a. Your height will increase on average 1 inch a year. b. Your height will increase on average 2 inches a year. c. Your height will increase on average 3 inches a year. d. Your height will increase on average 4 inches a year. ANS: B Between the ages of 6 and 12 years, children grow an average of 5 cm (2 inches) per year. DIF: Cognitive Level: Applying REF: MCS: 569 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 26. What does the nurse understand about caloric needs for school-age children? a. The caloric needs for the school-age children are the same as for other age groups. b. The caloric needs for school-age children are more than they were in the preschool years. c. The caloric needs for school-age children are lower than they were in the preschool years. d. The caloric needs for school-age children are greater than they will be in the adolescent years. ANS: C School-age children do not need to dbeasfe carefully, as promptly, or as frequently as before. Caloric needs are lower than they were in the preschool years and lower than they will be during the coming adolescent growth spurt. DIF: Cognitive Level: Understanding REF: MCS: 570 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 27. The school nurse is teaching female school-age children about the average age of puberty. What is the average age of puberty for girls? a. 10 years b. 11 years c. 12 years d. 13 years ANS: C The average age of puberty is 12 years in girls. DIF: Cognitive Level: Applying REF: MCS: 571 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. The school nurse is teaching male school-age children about the average age of puberty. What is the average age of puberty for boys? a. 12 years b. 13 years c. 14 years d. 15 years ANS: C The average age of puberty is 14 years in boys. Boys experience little sexual maturation during preadolescence. DIF: Cognitive Level: Applying REF: MCS: 571 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 29. A female school-age child asks the school nurse, How many pounds should I expect to gain in a year? The nurse should give which response? a. You will gain about 2.4 to 4.6 lb per year b. You will gain about 3.4 to 5.6 lb per year. c. You will gain about 4.4 to 6.6 lb per year. d. You will gain about 5.5 to 7.6 lb per year. ANS: C Between the ages of 6 and 12 years, children will almost double in weight, increasing 2 to 3 kg (4.4 to 6.6 lb) per year. DIF: Cognitive Level: Applying REF: MCS: 569 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 30. The nurse is explaining about the developmental sequence in childrens capacity to conserve matter to a group of parents. What type of matter is last in the sequence for a child to develop? a. Mass b. Length c. Volume d. Numbers ANS: C There is a developmental sequence in childrens capacity toecrovnesmatter. C hildren usually grasp conservation of numbers (ages 5 to 6 years) before conservation of substance. Conservation of liquids, mass, and length usually is accomplished at about ages 6 to 7 years, conservation of weight sometime later (ages 9 to 10 years), and conservation of volume or displacement last (ages 9 to 12 years). DIF: Cognitive Level: Applying REF: MCS: 573 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 31. The school nurse is presenting sexual information to a group of school-age girls. What approach should the nurse take when presenting the information? a. Put off answering questions. b. Give technical terms when giving the presentation. c. Treat sex as a normal part of growth and development. d. Plan to give the presentation with boys and girls together. ANS: C When nurses present sexual information to children, they should treat sex as a normal part of growth and development. Nurses should answer questions honestly, matter-of-factly, and at the childrens level of understanding. School-age children may be more comfortable when boys and girls are segregated for discussions. DIF: Cognitive Level: Applying REF: MCS: 580 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 32. The parents of a 5-year-old child ask the nurse, How many hours of sleep a night does our child need? The nurse should give which response? a. A 5-year-old child requires 8 hours of sleep. b. A 5-year-old child requires 9.5 hours of sleep. c. A 5-year-old child requires 10 hours of sleep. d. A 5-year-old child requires 11.5 hours of sleep. ANS: D Sleep requirements decrease during school-age years; 5-year-old children generally require 11.5 hours of sleep. DIF: Cognitive Level: Applying REF: MCS: 593 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. What growth and development milestones are expected between the ages of 8 and 9 years? (Select all that apply.) a. Can help with routine household tasks b. Likes the reward system for accomplished tasks c. Uses the telephone for practical purposes d. Chooses friends more selectively e. Goes about home and community freely, alone or with friends f. Enjoys family time and is respectful of parents ANS: A, B, E Children between the age of 8 and 9 years accomplish many growth and development milestones, including helping with routine household tasks, liking the reward system when a task is accomplished well, and going out with friends or alone more independently and freely. Using the telephone for practical reasons, choosing friends more selectively, and finding enjoyment in family with new-found respect for parents are tasks accomplished between the ages of 10 and 12 years. DIF: Cognitive Level: Applying REF: MCS: 584 TOP: NursoicnegssP:rAssessment iMenStC: Cl Needs: Health Promotion and Maintenance 2. The nurse is planning strategies to assist a slow-to-warm child to try new experiences. What strategies should the nurse plan? (Select all that apply.) a. Attend after-school activities with a friend. b. Suggest the child move quickly into a new situation. c. Avoid trying new experiences until the child is ready. d. Allow the child to adapt to the experience at his or her own pace. e. Contract for permission to withdraw after a trial of the experience. ANS: A, D, E The nurse should encourage slow-to-warm children to try new experiences but allow them to adapt to their surroundings at their own speed. Pressure to move quickly into new situations only strengthens their tendency to withdraw. After-school activities canabuesea fcor trieoanc, but attending with a friend or contracting for permission to withdraw taefr a t rial of a cspifeied number of times may provide them with sufficient incentive to try. DIF: Cognitive Level: Applying REF: MCS: 572 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. The nurse is planning strategies to assist difficult or easily distracted children whenythe participate in activities. What astregies should the nurse plan? (Select a ll .t)hat apply a. Role-play before the activity. b. Handle behavior with firmness. c. Acquaint them with what to expect. d. Be patient with inappropriate behavior. e. Dont give them much information about the activity. ANS: A, B, C, D Difficult or easily distracted children may benefit from practice sessions in which they are prepared for a given event by role-playing, visiting the site, reading or listening to stories, or using other methods to acquaint them with what to expect. Nurses need to handle children with difficult temperaments with exceptional patience, firmness, and understanding so they can learn appropriate behavior in their interactions with others. DIF: Cognitive Level: Applying REF: MCS: 572 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 4. Characteristics of bullies include what? (Select all that apply.) a. Female b. Depressed c. Good peer relationships d. Poor academic performance e. Exposed to domestic violence ANS: B, D, E Children who are sbuallie re likely to be male, depre psoedo,r hav maciacdpeerformance, be exposed to domestic violence, have poor peer relationships, and have poor communication with their parents. DIF: Cognitive Level: Understanding REF: MCS: 577 TOP: NursoicnegssP:rAssessment iMenStC: Cl Needs: Health Promotion and Maintenance 5. A school-age child has been a victim of ybiunlgl . What characteristics does the nurse assess for in this child? (Select all that apply.) a. Anxiety b. Outgoing c. Low self-esteem d. Psychosomatic complaints e. Good academic performance ANS: A, C, D Victims of bullying are at increased risk for low lsfe -esteem; anxiety; depression; feelings of insecurity and loneliness; poor academic performance; and psychosomatic complaints such as feeling tense, tired, or dizzy. DIF: Cognitive Level: Applying REF: MCS: 577 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. The school nurse recognizes that children respond to stress by using which tactics? (Select all that apply.) a. Passivity b. Delinquency c. Daydreaming d. Delaying tactics e. Becoming outgoing ANS: B, C, D Children respond to stress by using coping mechanisms that include internalizing symptoms such as withdrawal, delaying tactics, and daydreaming, along with externalizing symptoms such as aggression and delinquency. DIF: Cognitive Level: Analyzing REF: MCS: 588 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is teaching parents about safety for their latchkey children. What should the nurse include in the teaching osens?si(Select all that apply.) a. Teach the child first-aid procedures. b. Keep the key in an easy place to find. c. Teach the child weather-related safety. d. Teach the child to open the door for delivery people. e. Emphasize fire safety rules and conduct practice fire drills. ANS: C, E Safety for latchkey children includes teaching the child first-aid procedures, teaching the child weather-related safety, and emphasizing fire safety rules and conducting practice fire drills. Teach the child not to display keys and to always lock doors. The child should be taught to not open the door to anyone, even delivery people. DIF: Cognitive Level: Applying REF: MCS: 590 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. The school nurse is teaching bicycle safety to a group of school-age children. What should the nurse include in the session? (Select all that apply.) a. Ride double file when possible. b. Watch for and yield to pedestrians. c. Only ride double with someone your own size. d. Ride bicycles with traffic away from parked cars. e. Keep both hands on the handlebars except when signaling. ANS: B, D, E Bicycle safety includes watching for and yielding to pedestrians, riding bicycles with traffic away from parked cars, and keeping both hands on handlebars except when signaling. It is best to ride single file, not double file, and never to ride double on a bicycle. DIF: Cognitive Level: Applying REF: MCS: 604 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. Parents are concerned about their child riding an all-terrain vehicle. What should the enuters ll the parents about esaofef us all-terrain vehicles? (Select all that apply.) a. Restrict riding to familiar terrain. b. Limit street use to the neighborhood. c. Nighttime riding should not be allowed. d. Vehicles should not carry more than two persons. e. Vehicles should include seat belts, roll bars, and automatic headlights. ANS: A, C, E Safe use of rarlal-itne vhicleseinc ludes restricting riding to familiar terrain; not allowing nighttime riding; and assuring the vehicle has seat belts, roll bars, and automatic headlights. Street use should not be allowed, and the vehicle should not carry more than one person. DIF: Cognitive Level: Applying REF: MCS: 601 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. What are the goals of organized athletics for preadolescent children? (Select all that apply.) a. Physical fitness b. Basic motor skills c. A positive self-image d. Commitment to winning ANS: A, B, C The goals of organized athletics for preadolescent children include physical fitness, basic motor skills, and a positive self-image. The commitment is to the values of teamwork, fair play, and sportsmanship, not to winning. Chapter 16.Health Problems of the School-Age Child MULTIPLE CHOICE 1. Deficiency of which vitamin or mineral results in an inadequate inflammatory response? a. A b. B1 c. C d. Zinc ANS: A A deficiency of vitamin A results in an inadequate inflammatory response. Deficiencies of vitamins B1 and tCinredseul epithelialization. creased collagen formation. A deficiency of zinc leads to impaired DIF: Cognitive Level: Understanding REF: MCS: 613 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. An occlusive dressing is applied to a large abrasion. This is advantageous because the dressing will accomplish what? a. Deliver vitamin C to the wound. b. Provide an antiseptic for the wound. c. Maintain a moist environment for healing. d. Promote mechanical friction for healing. ANS: C Occlusive dressings, such as Acuderm, are not adherent to the wound site. They provide a moist wound surface and insulate the wound. The dressing does not have vitamin C or antiseptic capabilities. Acuderm protects against friction. DIF: Cognitive Level: Analyzing REF: MCS: 613 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. A toddler has a deep laceration contaminated with dirt and sand. Before closing the wound, the nurse should irrigate with twshoalution? a. Alcohol b. Normal saline c. Povidoneiodine d. Hydrogen peroxide ANS: B Normal saline is the only acceptable fluid for irrigation listed. The nurse should cleanse the wound with a forced stream of normal saline or water. Alcohol is not used for wound irrigation. Povidoneiodine is contraindicated for cleansing fresh, open wounds. Hydrogen peroxide can cause formation of subcutaneous gas when applied under pressure. DIF: Cognitive Level: Analyzing REF: MCS: 616 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. The nurse should know what about Lyme disease? a. Very difficult to prevent b. Easily treated with oral antibiotics in stages 1, 2, and 3 c. Caused by a spirochete that enters the skin through a tick bite d. Common in geographic areas where the soil contains the mycotic spores that cause the disease ANS: C Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve shirts and long pants tucked into socks should be worn. Early treatment of the erythema migrans (stage 1) can prevent the development of mLye disease. L yme disease is caused by a spirochete, not mycotic spores. DIF: Cognitive Level: Understanding REF: MCS: 629 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 5. The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action? a. Soak his hands in warm water. b. Apply Burows solution compresses. c. Rinse his hands in cold running water. d. Scrub his hands thoroughly with antibacterial soap. ANS: C The first recommended action is to rinse his hands in cold running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. Soaking his hands in warm water is effective for hsoinogt the skin lesions after the dermatitis has begun. Antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread. DIF: Cognitive Level: Applying REF: MCS: 620 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. A 6-year-old boy with very fair skin will be joining his family during a beach vacation. What should the nurse recommend? a. Keep him off the beach during the daytime hours. b. Use sunscreen with an SPF of at least 15 and reapply it every 2 to 3 hours. c. Apply a topical sunscreen product with an SPF of 30 in the morning. d. Dress him in long pants and long-sleeved shirt and keep him under a beach umbrella. ANS: B A sunscreen with an SPF (sun protection factor) of at least 15 is recommended. The sunscreen should be reapplied every 2 to 3 hours and after the child is in the water or sweating excessively. During a beach vacation, avoiding the beach during daytime hours is impractical. The highest risk of sun exposure is from 10 AM to 3 PM. Sunlight exposure should be limited during this time. An SPF of 30 is good, but reapplying it is necessary every 2 to 3 hours and when the child gets wet. Long pants and a shirt are impractical. The beach umbrella can be used with the sunscreen to limit exposure to the sun. DIF: Cognitive Level: Applying REF: MCS: 621 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I7n. tTeghreitmy anagement of a child who has just been stung by a bee or wasp should include applying what? a. Cool compresses b. Antibiotic cream c. Warm compresses d. Corticosteroid cream ANS: A Bee or wasp stings are initially treated by carefully removing the stinger, cleansing with soap and water, applying cool compresses, and using common household agents such as lemon juice or a paste made with ainspainrd baking soda. Antibiotic cream icsesusnanrey unl ess a secondary infection occurs. Warm compresses are avoided. Corticosteroid cream oist n tpaorf the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated. DIF: Cognitive Level: Applying REF: MCS: 627 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 8. A parent calls the clinic nurse because his 7-year-old child was bitten by a black widow spider. What action should the nurse advise the parent to take? a. Apply warm compresses. b. Carefully scrape off the stinger. c. Take the child to the emergency department. d. Apply a thin layer of corticosteroid cream. ANS: C The venom of the black widow spider has a neurotoxic effect. The parent should take the child to the emergency department for treatment with antivenin and muscle relaxants as needed. Warm compresses increase the circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream has no effect on the venom. DIF: Cognitive Level: Applying REF: MCS: 628 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I9n. tAegsrcithyool-age child has been bitten on the leg by a large snake that may be poisonous. During transport to an emergency facility, what should the care include? a. Apply ice to the snakebite. b. Immobilize the leg with a splint. c. Place a loose tourniquet distal to the bite. d. Apply warm compresses to the snakebite. ANS: B The leg should be immobilized. Ice decreases blood flow to the area, which allows the venom to work tmruocrtei des on and decreases the effect of antivenin on the natural immune mechanisms. A loose tourniquet is placed proximal, not distal, to the area of the bite to delay the flow of lymph. This can delay movement of the venom into the peripheral circulation. The tourniquet should be applied so that a pulse can be felt distal to tbhitee. Warmth i ncreases circulation to the area and helps the toxin into the peripheral circulation. DIF: Cognitive Level: Applying REF: MCS: 631 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 10. Parents phone the nurse and say that their child just knocked out a permanent tooth. What should the nurses instructions to the parents include? a. Place the tooth in dry container for transport. b. Hold the tooth by the crown and not by the root area. c. Transport the child and tooth to a dentist within 18 hours. d. Take the child to hospital emergency department if his or her mouth is bleeding. ANS: B It is important to avoid touching the root area of the tooth. The tooth should be held by the crown area; rinsed in milk, saline, or running water; and reimplanted as soon as possible. The tooth is kept moist during transport to maintain viability. Cold milk is the most desirable medium for transport. The child needs to be seen by a dentist as soon as possible. Tooth evulsion causes a large amount of bleeding. The child will need to be seen by a dentist because of the loss of a tooth, not the bleeding. DIF: Cognitive Level: Applying REF: MCS: 634 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 1In1t.ePgarirteynts are concerned that their 6-year-old son continues to occasionally wet the bed. What does the nurse explain? a. This is likely because of increased stress at home. b. Enuresis usually ceases between 6 and 8 years of age. c. Drug therapy will be prescribed to treat the enuresis. d. Testing will be necessary to determine what type of kidney problem exists. ANS: B Further data must be gathered before the diagnosis of enuresis is made. Enuresis is the inappropriate voiding of urine at least twice a week. This child does meet the age criterion, but the parents need to be questioned about and keep a diary on the frequency of events. If the bedwetting is infrequent, parents can be encouraged that the child may grow out of this behavior. Drug therapy will not be prescribed until a more complete evaluation is done. Additional assessment information must be gathered, but at this time, there is no indication of renal disease. DIF: Cognitive Level: Applying REF: pp. 634-635 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is assisting the family of a child with a history of encopresis. What should be included in the nurses discussion with the family? a. Instruct the parents to sit the child on the toilet at twice-daily routine intervals. b. Instruct the parents that the child will probably need to have daily enemas. c. Suggest the use of stimulant cathartics weekly. d. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress. ANS: D Children may be unaware of a prior sensation and be unable to control the urge after it begins. They may be so accustomed to bowel accidents that they may be unable to smell or feel them. Family counseling is directed toward reassurance that most problems resolve successfully, although relapses during periods of stress are possible. Sitting the child on the toilet is not recommended because it may intensify the parentchild conflict. Enemas may be needed for impactions, but long-term use prevents the child from assuming responsibility for defecation. Stimulant cathartics may cause cramping that can frighten children. DIF: Cognitive Level: Applying REF: pp. 636-637 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 13. What is an important consideration in the diagnosis of attention deficit hyperactivity disorder (ADHD)? a. Learning disabilities are apparent at an early age. b. The child will always be distracted by external stimuli. c. Parental observations of the childs behavior are most relevant. d. It must be determined whether the childs behavior is age appropriate or problematic. ANS: D The diagnosis of ADHD is complex. A multidisciplinary evaluation should be done to determine whether the childs behavior is appropriate for the developmental age or whether it is problematic. Learning disabilities are ullsyunao t evident until the child enters school. Each child with ADHD responds fdeifrentulyli.toSs tim moe c hildren are distracted by internal stimuli and others by external stimuli. Parents can only provide one viewpoint of the childs behavior. Many observers should be asked to provide input with structured tools to facilitate the diagnosis. DIF: Cognitive Level: Understanding REF: MCS: 639 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 14. The nurse is facilitating a conference between theaechers and parents of a 7-year-old child newly diagnosed with attention deficit hyperactivity disorder (ADHD). What does the nurse stress? a. Academic subjects should be taught in the afternoon. b. Low-interest activities in the classroom should be minimized. c. Visual references should accompany verbal instruction. d. The childs environment should be visually stimulating. ANS: C Verbal instructions should always be accompanied by visual or written instructions. This provides the child with reinforcement and a reference to expectations. Academic subjects should be taught in the morning when the child is experiencing the effects of the morning dose of medication. Low-interest activities should be mixed with high-interest activities to maintain the childs attention. Environmental stimulation should be minimized to help eliminate distractions that can overexcite the child. DIF: Cognitive Level: Applying REF: MCS: 641 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I1n5t.eWgrihtayt is characteristic of children with posttraumatic stress disorder (PTSD)? a. Denial as a defense mechanism is unusual. b. Traumatic effects cannot remain indefinitely. c. Previous coping strategies and defense mechanisms are not useful. d. Children often play out the situation over and over again. ANS: D The third phase of adjustment to PTSD involves the children playing out the situation over and over toocot me t erms with their fears. Denial is frequently used as a defense mechanism during the second phase. For some children, traumatic effects can mreain i ndefinitely. Coping is a learned response. During the third stage, the children can be helped toeutsheir copi ngasttergies to deal with their fears. DIF: Cognitive Level: Understanding REF: MCS: 643 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 16. A 9-year-old child has just been diagnosed with recurrent abdominal pain (RAP). In preparing for discharge, the nurse should include what in the home care instructions to the parents? a. Following a high-fiber diet b. Using stimulant laxatives c. Using ice packs on the abdomen when pain occurs d. Sitting on the toilet for 30 minutes after each meal ANS: A A high-fiber diet with possible addition of bulk laxatives is beneficial for children with RAP. Bulk-forming laxatives such as psyllium are recommended. Stimulant laxatives may produce painful cramping for the child. Warm packs, such as a heating pad, may help ease the discomfort. Bowel training is recommended to assist the child in establishing regular bowel habits. Thirty minutes is too long for the child to sit on the toilet. The time should be limited to 15 minutes. DIF: Cognitive Level: Applying REF: MCS: 646 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I1n7t.eWgrihtayt is a characteristic of children with depression? a. Increased range of affective response b. Tendency to prefer play instead of schoolwork c. Change in appetite resulting in weight loss or gain d. Preoccupation with need to perform well in school ANS: C Physiologic characteristics of children with depression include changes in appetite resulting in weight loss or gain, nonspecific complaints of not feeling well, alterations in sleeping patterns, insomnia or hypersomnia, and constipation. Children who are depressed have sad facial expressions with absent or diminished range of affective response. These children withdraw from previously enjoyed activities and engage in solitary play or work with a lack of interest in play. They are uninterested in doing homework or achieving in school, resulting in lower grades. DIF: Cognitive Level: Understanding REF: MCS: 647 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 18. The school nurse is reviewing the process of wound healing. What is the initial response at the site of injury? a. Contraction b. Maturation c. Fibroplasia d. Inflammation ANS: D The initial response at the site of injury is inflammation, a vascular and cellular response that prepares the tissues for the subsequent repair process. Fibroplasia (granulation or proliferation), the second phase of healing, lasts from 5 days to 4 weeks. During contraction and maturation, the third and fourth phases of wound healing, collagen continues to be deposited and organized into layers, compressing the new blood vessels and gradually stopping blood flow across the wound. DIF: Cognitive Level: Understanding REF: MCS: 611 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 19. An older school-age child asks the nurse, What is the reason for othpiisctal corticosteroid cream? What rationale should the nurse give? a. The cream is used for an antifungal effect. b. The cream is used for an analgesic effect. c. The cream is used for an antibacterial effect. d. The cream is used for an anti-inflammatory effect. ANS: D The glucocorticoids are the therapeutic agents used most widely for skin disorders. Their local anti-inflammatory effects are merely palliative, so the medication must be applied until the disease state undergoes a remission or the causative agent is eliminated. It does not have an antifungal, analgesic, or antibacterial effect. DIF: Cognitive Level: Applying REF: MCS: 614 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n0t.eTgrhietynurse is caring for a child with a decubiti on the buttocks. The nurse notes that the dressing covering the decubiti is loose. What action should the nurse implement? a. Retape the dressing. b. Remove the dressing. c. Change the dressing. d. Reinforce the dressing. ANS: C Dressings should always be changed when they are loose or soiled. They should be changed more frequently in areas where contamination is likely (e.g., sacral area, buttocks, tracheal area). The dressing should not be retaped, removed, or reinforced. DIF: Cognitive Level: Applying REF: MCS: 613 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 21. The nurse is explaining the purpose of using a vacuum-assisted closure (VAC) device to assist in the healing of a wound. What should the nurse explain as the purpose of using a VAC device? a. The device will decrease capillary flow. b. The device applies gentle continuous suction. c. The device will allow the wound to remain open. d. The device will prevent the formation of granulation tissue. ANS: B A VAC device uses a technique that involves placing a foam dressing into the wound, covering it with an occlusive dressing, and applying gentle continuous suction. The negative pressure of the suction is applied from the foam dressing to the wound surfaces. The mechanical force removes excess fluids from the wound, stimulates formation of granulation tissue, restores capillary flow, and fosters closure of the wound. DIF: Cognitive Level: Applying REF: MCS: 617 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n2t.eAgricthyild has had contact with some poison ivy. The school nurse understands that the full- blown reaction should be evident after how many days? a. 1 day b. 2 days c. 3 days d. 4 days ANS: B The full-blown reaction to poison ivy is evident after about 2 days, with linear patches or streaks of erythemic, raised, fluid-filled vesicles; swelling; and persistent itching at the site of contact. DIF: Cognitive Level: Understanding REF: MCS: 619 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 23. The nurse is admitting a child with frostbite. What health care prescription should the nurse question and verify? a. Massage the injured tissue. b. Apply a loose dressing after rewarming. c. Avoid any application of dry heat to the area. d. Administer acetaminophen (Tylenol) for discomfort. ANS: A A frostbite victim should not have injured tissue rubbed. It is contraindicated because it can cause damage by urureptof tcarlyliszed cel ls. After rewarming, a loose dressing is applied to the affected skin, and analgesia is administered if indicated. Dry heat is not applied. DIF: Cognitive Level: Analyzing REF: MCS: 622 TOP: NursoicnegssP:rImplementation MSC: Client Needs: Safe and Effective Care Environment 24. The nurse understands that medications delivered by which route are more likely to cause a drug reaction? a. Oral b. Topical c. Intravenous d. Intramuscular ANS: C Drugs administered by the intravenous route are more likely to cause a reaction lt,han the ora topical, or intramuscular route. DIF: Cognitive Level: Understanding REF: MCS: 623 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is caring for a child who has a temperature of 30 C (86 F). What physical effects of hypothermia should the nurse expect to observe in this child? (Select all that apply.) a. Reduced urinary output b. Injury to peripheral tissue c. Increased blood pressure d. Tachycardia e. Irritability with loss of consciousness f. Rigid extremities ANS: C, D, E Hypothermia has varying physical effects depending on the childs core temperature. At 30 C (86 F), a child would experience an increase in blood pressure, tachycardia, and irritability followed by a loss of consciousness. Reduced urinary output from a decrease of blood flow to the kidneys, injury to peripheral tissue, and rigid extremities are physical effects observed as the body temperature continues to decrease. DIF: Cognitive Level: Analyzing REF: pp. 622-623 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The nurse is teaching a school-age child about factors that can delay wound healing. What factors should the nurse include in the teaching session? (Select all that apply.) a. Deficient vitamin C b. Deficient vitamin D c. Increased circulation d. Dry wound environment e. Increase in white blood cells ANS: A, B, D Factors that delay wound healing are a dry wound environment (allows epithelial cells to dry), deficient vitamin C (inhibits formation of collagen fibers), iacnidendtef vitamin D (raetegsul growth and differentiation of cell types). Decreased, not increased, circulation delays healing. An increase in the white blood cell count may occur but does not delay healing. DIF: Cognitive Level: Applying REF: MCS: 612 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. The school nurse is assessing a childs severely scraped knee for infection. What are signs of a wound infection? (Select all that apply.) a. Odor b. Edema c. Dry scab d. Purulent exudate e. Decreased temperature ANS: A, B, D Signs of wound infection are odor, edema, and purulent exudate. Increased, not decreased, temperature indicates infection. A dry scab over the wound is part of the healing process. DIF: Cognitive Level: Applying REF: MCS: 615 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. The nurse is teaching parents of a school-age child how to cleanse small wounds. What should the nurse advise the parents to avoid using to cleanse a wound? (Select all that apply.) a. Alcohol b. Normal saline c. Tepid water d. Povidoneiodine e. Hydrogen peroxide ANS: A, D, E Caution caregivers to avoid cleansing the wound with povidoneiodine, alcohol, and hydrogen peroxide because these products disrupt wound healing. Normal saline and tepid water are safe to use when cleansing wounds. DIF: Cognitive Level: Applying REF: MCS: 616 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. The emergency department nurse is admitting a child with a temperature of 35 C (95 F). What physical effects of hypothermia should the nurse expect etorvoebisn this child? (Select all that apply.) a. Bradycardia b. Vigorous shivering c. Decreased respiratory rate d. Decreased intestinal motility e. Task performance is impaired ANS: B, D, E Hypothermia has varying physical effects depending on the childs core temperature. At 35 C (95 F), a child would experience vigorous shivering, decreased intestinal motility, and task performance impairment. Bradycardia and decreased respiratory rate are physical effects observed as the body temperature continues to decrease. DIF: Cognitive Level: Analyzing REF: pp. 622-623 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6. The nurse is caring for a child with psoriasis. What local manifestations does the nurse expect to assess in this child? (Select all that apply.) a. Development of wheals b. First lesions appear in the scalp c. Round, thick, dry reddish patches d. Lesions appear in intergluteal folds e. Patches are covered with coarse, silvery scales ANS: B, C, E Local manifestations of psoriasis include lesions that appear in the scalp initially and round, thick dry patches covered with coarse, silvery scales. Development of wheals is seen in urticaria. Lesions in intergluteal folds are characteristic of intertrigo. DIF: Cognitive Level: Analyzing REF: MCS: 626 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. The nurse is caring for a child with erythema multiforme (Stevens-Johnson syndrome). What local manifestations does the nurse expect to assess in this child? (Select all that apply.) a. Papular urticaria b. Erythematous papular rash c. Lesions absent in the scalp d. Lesions enlarge by peripheral expansion e. Firm papules that may be capped by vesicles ANS: B, C, D Local manifestations of erythema multiforme include an erythematous popular rash, lesions involving most skin surfaces except the scalp and lesions that enlarge by peripheral expansion. Papular urticaria and firm papules capped by vesicles are characteristics of an insect bite. DIF: Cognitive Level: Analyzing REF: MCS: 626 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. The nurse is caring for a child with neurofibromatosis.aWl mhat loc anifestations does the nurse expect tonasthseissschi ild? (Sele t c all that apply.) a. Pigmented nevi b. Axillary freckling c. Caf-au-lait spots d. Slowly growing cutaneous neurofibromas e. Wheals that spread irregularly and fade within a few hours ANS: A, B, C, D Local manifestations of neurofibromatosis include pigmented nevi, axillary freckling, caf-au-lait spots, and slowly growing cutaneous neurofibromas. Wheals that spread irregularly and fade within a few hours are characteristic of urticaria. DIF: Cognitive Level: Analyzing REF: MCS: 626 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity COMPLETION 1. A health care provider prescribes methylphenidate hydrochloride (Ritalin), PO, 20 mg, twice a day, for a child with attention deficit hyperactivity disorder. The medication label states: Methylphenidate hydrochloride (Ritalin), 10 mg/1 tablet. The nurse prepares to administer one dose. How many tab(s) should the nurse prepare to administer one dose? Fill in the blank. Record your answer as a whole number. ANS: 2 Chapter 17.Health Promotion of the Adolescent and Family MULTIPLE CHOICE 1. How does the onset of the pubertal growth spurt compare in girls and boys? a. In girls, it occurs about 1 year before it appears in boys. b. In girls, it occurs about 3 years before it appears in boys. c. In boys. it occurs about 1 year before it appears in girls. d. It is about the same in both boys and girls. ANS: A The average age of onset is 9 1/2 years for girls and 10 1/2 years for boys. Although pubertal growth spurts may occur in girls 3 years before it appears in boys on an individual basis, the average difference is 1 year. Usually girls begin their pubertal growth spurt earlier than boys. DIF: Cognitive Level: Applying REF: MCS: 658 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. In girls, twihsathe initial indication of puberty? a. Menarche b. Growth spurt c. Breast development d. Growth of pubic hair ANS: C In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche. The usual sequence of secondary sexual characteristic development in girls is breast changes, a rapid increase in height and weight, growth of pubic hair, appearance of axillary hair, menstruation (menarche), and abrupt deceleration of linear growth. DIF: Cognitive Level: Understanding REF: MCS: 654 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. Girls experience an increase in weight and fat deposition during puberty. What do nursing considerations tredlato thi s ilnucde? a. Give reassurance that these changes are normal. b. Suggest dietary measures to control weight gain. c. Encourage a low-fat diet to prevent fat deposition. d. Recommend increased exercise to control weight gain. ANS: A A certain amount of fat is increased along with lean body mass to fill the characteristic contours of the adolescents gender. A healthy balance must be achieved between expected healthy weight gain and obesity. Suggesting dietary measures or increased exercise to control weight gain would not be recommended unless weight gain was excessive because eating disorders can develop in this group. Some fat deposition is essential for normal hormonal regulation. Menarche is delayed in girls with body fat contents that are too low. DIF: Cognitive Level: Applying REF: MCS: 655 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. In boys, what is the initial indication of puberty? a. Voice changes b. Growth of pubic hair c. Testicular enlargement d. Increased size of penis ANS: C Testicular enlargement is the first change that signals puberty in boys; it usually occurs between the ages of 9 1/2 and 14 years during Tanner stage 2. Voice change occurs between Tanner stages 3 and 4. Fine pubic hair may occur at the base of the penis; darker hair occurs during Tanner stage 3. The penis enlarges during Tanner stage 3. DIF: Cognitive Level: Understanding REF: MCS: 655 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. According to Piaget, adolescents tend to be in what stage of cognitive development? a. Concrete operations b. Conventional thought c. Postconventional thought d. Formal operational thought ANS: D Cognitive thinking culminates in the capacity for abstract thinking. This stage, the period of formal operations, is Piagets fourth and last stage. Concrete operations usually occur between ages 7 and 11 years. Conventional and postconventional thought refers to Kohlbergs stages of moral development. DIF: Cognitive Level: Understanding REF: MCS: 658 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 6. What aspects of cognition develop during adolescence? a. Ability to see things from the point of view of another b. Capability of using a future time perspective c. Capability of placing things in a sensible and logical order d. Progress from making judgments based on what they see to making judgments based on what they reason ANS: B Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years), children exhibit thought processes that enable them to see things from the point of view of another, place things in a sensible and logical order, and progress from making judgments based on what they see to making judgments based on what they reason. DIF: Cognitive Level: Understanding REF: pp. 658-659 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. Adolescents often do not use reasoned decision making when issues such as substance abuse and sexual behavior are involved. What is this because of? a. They tend to be immature. b. They do not need to use reasoned decision making. c. They lack cognitive skills to use reasoned decision making. d. They are dealing with issues that are stressful and emotionally laden. ANS: D In the face of time pressures, spoenr al st ress, or overwhelming peer pressure, young people are more likely to abandon rational thought processes. Many of the health-related decisions adolescents confront are emotionally laden or new. Under such conditions, many people do not use their capacity for formal decision making. The majority of sadhoalveescceongtnitive skills and apreabcle of reasoned decision making. Stress affects their ability to process information. Reasoned decision making should be used in issues that are crucial suchsatasnscub sexual behavior. DIF: Cognitive Level: Analyzing REF: MCS: 659 e abuse and TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 8. What is most descriptive of the spiritual development of older adolescents? a. Beliefs become more abstract. b. Rituals and practices become increasingly important. c. Strict observance of religious customs is common. d. Emphasis is placed on external manifestations, such as whether a person goes to church. ANS: A Because of their abstract thinking abilities, adolescents are able to interpret analogies and symbols. Rituals, practices, and strict observance of religious customs become less important as adolescents question values and ideals of families. Adolescents question external manifestations when not supported by adherence to supportive behaviors. DIF: Cognitive Level: Understanding REF: MCS: 660 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity 9. According to Erikson, the psychosocial task of adolescence is developing what? a. Identity b. Intimacy c. Initiative d. Independence ANS: A Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Independence is not one of Eriksons developmental stages. DIF: Cognitive Level: Understanding REF: MCS: 660 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 10. What is true concerning the development of autonomy during adolescence? a. Development of autonomy typically involves rebellion. b. Development of autonomy typically involves parentchild conflicts. c. Parent and peer influences are opposing forces in the development of autonomy. d. Conformity to both parents and peers gradually declines toward the end of adolescence. ANS: D During middle and late adolescence, tchoenformity t oepnatrs and peers declines. Subjective feelings of self-reliance increase steadily over the adolescent years. Adolescents have genuine behavioral autonomy. Rebellion is not typically part of adolescence. It can occur in response to excessively controlling circumstances or to growing up in the absence of clear standards. Parent and peer relationships can play complementary roles in the development of a healthy degree of individual independence. DIF: Cognitive Level: Understanding REF: MCS: 661 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 11. What is true concerning masturbation during adolescence? a. Homosexuality is encouraged by the practice of masturbation. b. Many girls do not begin masturbation until after they have intercourse. c. Masturbation at an early age leads to sexual intercourse at an earlier age. d. Development of intimate relationships is delayed when masturbation is regularly practiced. ANS: B The age of first masturbation for girls is variable.mSeo begin masturbating i nyeadl ce;olescen many do not begin until after they have had intercourse. Boys typically begin masturbation in early adolescence. Masturbation provides an opportunity for esexlpf-loration. Both heterosexual and homosexual youth use masturbation. It does not affect the development of intimacy. DIF: Cognitive Level: Understanding REF: MCS: 662 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. A 16-year-old adolescent boy tells the school nurse that he is gay. The nurses response should be based on what? a. He is too young to have had enough sexual activity to determine this. b. The nurse should feel open to discussing his or her own beliefs about homosexuality. c. Homosexual adolescents do not have concerns that differ from those of heterosexual adolescents. d. It is important to provide a nonthreatening environment in which he can discuss this. ANS: D The nurse needs to bneanopdenonjudgmental in interactions with adolescents. This will provide a safe environment in which to provide appropriate health care. Adolescence is when sexual identity develops. The nurses own beliefs should not bias the interaction with this student. Homosexual adolescents face very different lcehnagles as they grow up because of esotycsi response to homosexuality. DIF: Cognitive Level: Analyzing REF: MCS: 672 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 13. The development of sexual orientation during adolescence is what? a. Inflexible b. A developmental process c. Differs for boys and girls d. Proceeds in a defined sequence ANS: B The development of sexual orientation as a part of sexual identity includes several developmental milestones during late childhood and throughout adolescence. The sequence and time spent in phases are different for each individual. Boys and girls pass through the same developmental milestones. DIF: Cognitive Level: Understanding REF: MCS: 682 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. What is an important consideration for the school nurse planning a class on injury prevention for adolescents? a. Adolescents generally are not risk takers. b. Adolescents can anticipate the long-term consequences of serious injuries. c. Adolescents need to discharge energy, often at the expense of logical thinking. d. During adolescence, participation in sports should be limited to prevent permanent injuries. ANS: C The physical, sensory, and psychomotor development of adolescents provides a sense of strength and confidence. There is also an increase in energy coupled with risk taking that puts them at risk. eAsdcoenl ts are risk takers because their f eelings of indestructibility interfere twhi understanding of consequences. Sports can be a useful way forcaednotsletso discharge energy. Care must be taken to avoid overuse injuries. DIF: Cognitive Level: Applying REF: MCS: 674 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 15. The school nurse is teaching a class on injury prevention. What should be included when discussing firearms? a. Adolescents are too young to use guns properly for hunting. b. Gun carrying among adolescents is on the rise, primarily among inner-city youth. c. Nonpowder guns (air rifles, BB guns) are a relatively safe alternative to powder guns. d. Adolescence is the peak age for being a victim or offender in the case of injury involving a firearm. ANS: D The increase in gun availability in the general population is linked to increased gun deaths among children, especially adolescents. Gun carrying among adolescents is on the rise and not limited to the stereotypic inner-city youth. Adolescents can be taught to safely use guns for hunting, but they must be stored properly and used only with supervision. Nonpowder guns (air rifles, BB guns) cause almost as many injuries as powder guns. DIF: Cognitive Level: Applying REF: MCS: 674 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion andtMenannce 16. The nurse is explaining to an adolescent the rationale for administering a Tdap (tetanus, diphtheria, acellular pertussis) vaccine 3 years after the last Tde(tanus) b ooster. What should the nurse tell the adolescent? a. It is time for a booster vaccine. b. It is past the time for a booster vaccine. c. This vaccine will provide pertussis immunity. d. This vaccine will be the last booster you will need. ANS: C When the Tdap is used as a booster dose, it may be administered earlier than the previous 5-year interval to provide adequate pertussis immunity (regardless of interval from the last Td dose). It is not time or past time for a booster because they are required every 5 years. Another booster will be needed in 5 years, so it is not the last dose. DIF: Cognitive Level: Applying REF: MCS: 679 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Health Promotion and Maintenance 17. The nurse is preparing a pamphlet for parents of adolescents about guidance during the adolescent years. What suggestion should the nurse include in the pamphlet? a. Provide criticism when mistakes are made or when views are different. b. Use comparisons with older siblings or extended family to promote good outcomes. c. Begin to disengage from school functions to allow the adolescent to gain independence. d. Provide clear, reasonable limits and define consequences when rules are broken. ANS: D An anticipatory guideline to include when teaching parents of adolescents is to provide clear, reasonable limits and have clear consequences when rules are broken. Parents should avoid criticism when mistakes are made and should allow opportunities for the teen to voice different views and opinions. Parents should try to avoid comparing the teen with a sibling or extended family member. Parents should try to be more engaged in the teens school functions to show support and unconditional love. DIF: Cognitive Level: Applying REF: MCS: 683 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 18. A 12-year-old girl asks the nurse about carn in What response should the nurse give? ease in clear white odorless vaginal discharge. a. This may mean a yeast infection. b. This is normal before menstruation starts. c. This is caused by an increase in progesterone. d. This is possibly a sign of a sexually transmitted infection. ANS: B Early in puberty, there is often an increase in normal vaginal discharge (physiologic leukorrhea) associated with uterine development. Girls or ethnetisrmpary be concerned that this vaginal discharge is a sign of infection. The nurse can reassure them that the discharge is normal and a sign that the uterus pisaprirneg for menstruation. It is caused by an increase in estrogen, not progesterone. DIF: Cognitive Level: Applying REF: MCS: 654 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The school nurse recognizes that pubertal delay in girls is considered if breast development has not occurred by which age? a. 10 years b. 11 years c. 12 years d. 13 years ANS: D Girls may be considered to have pubertal delay if breast development has not occurred by age 13 years or if menarche has not occurred within 2 to 2 1/2 years of the onset of breast development. DIF: Cognitive Level: Analyzing REF: MCS: 656 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. The school nurse recognizes that pubertal delay in boys is considered if no enlargement of the testes or scrotal changes have occurred by what age? a. 11 1/2 to 12 years b. 12 1/2 to 13 years c. 13 1/2 to 14 years d. 14 1/2 to 15 years ANS: C Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the testes or scrotal changes by ages 13 1/2 to 14 years or if genital growth is not complete 4 years after the testicles begin to enlarge. DIF: Cognitive Level: Analyzing REF: MCS: 657 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 21. The school nurse is teaching an adolescent about social networking and texting on phones. What statement by the adolescent dinicates a need f or hfuerrt t eaching? a. Social networking can help me develop interpersonal skills. b. I will have an opportunity to interact with people like myself. c. My text messaging during class time in school will not cause any disruption. d. I should be cautious, as the online environment can create opportunities for cyberbullying. ANS: C Internet chatrooms and social networking sites have created a more public arena for trying out identities and developing interpersonal skills with a wider network of people, occasionally with anonymity. This can create opportunities for young people who have a limited access toifernds (because of rural location, shyness, or rare chronic conditions) to interact with people like themselves. Both the online and text environment can create opportunities for cyberbullying, in which teens engage in insults, harassment, and publicly humiliating statements online or on cell phones. Text messaging and instant messaging via cell phones has become a common activity and can sometimes be disruptive during school. If the adolescent indicates it will not be disruptive, further teaching is needed. DIF: Cognitive Level: Applying REF: MCS: 667 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. The school nurse recognizes that adolescents should get how many hours of sleep each night? a. 6 hours b. 7 hours c. 8 hours d. 9 hours ANS: D Adolescents should generally get around 9 hours of sleep each night. DIF: Cognitive Level: Understanding REF: MCS: 680 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 23. The nurse is assessing the Tanner stage in an adolescent afelem. T he nurse recognizes that the stages are based on which? a. The stages of vaginal changes b. The progression of menstrual cycles to regularity c. Breast size and the shape and distribution of pubic hair d. The development of fat deposits around the hips and buttocks ANS: C In females, the Tanner stages describe pubertal development based on breast size and the shape and distribution of pubic hair. The stages of vaginal changes, epsrosigorn of menstrual cycles to regularity, and the development of fat deposits occur during puberty but are not used for the Tanner stages. DIF: Cognitive Level: Understanding REF: MCS: 654 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. The nurse is assessing the Tanner stage in an adolescent male. The nurse recognizes that the stages are based on what? a. Hair growth on the face and chest b. Changes in the voice to a deeper timbre c. Muscle growth in the arms, legs, and shoulders d. Size and shape of the penis and scrotum and distribution of pubic hair ANS: D In males, the Tanner stages describe pubertal development based on the size and shape of the penis and scrotum and the shape and distribution of pubic hair. During puberty, hair begins to grow on the face and ;cht est he voice becomes deeper; and muscles grow in tahrme s, legs, and shoulders, but these are not used for the Tanner stages. DIF: Cognitive Level: Understanding REF: MCS: 654 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is caring for children on an adolescent-only unit. What growth and development milestones should the nurse expect from 11- and 14-year-old adolescents? (Select all that apply.) a. Self-centered with increased narcissism b. No major conflicts with parents c. Established abstract thought process d. Have a rich, idealistic fantasy life e. Highly value conformity to group norms f. Secondary sexual characteristics appear ANS: B, E, F Growth and development milestones in the 11- to 14-year-old age group include minimal conflicts with parents (compared with the 15- to 17-year-old age group), a high value placed on conformity to the norm, and the appearance of secondary sexual characteristics.lSf e - centeredness and narcissism are seen in t1h5e - to 17-year-old age group along with a rich and idealistic fantasy life. Abstract thought processes are not lwl est ablished until the 18- to 20- year-old age group. DIF: Cognitive Level: Applying REF: MCS: 660 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 2. What are characteristics of early adolescence (1114 years) with regard to nidtiety? (Select all that apply.) a. Mature sexual identity b. Increase in self-esteem c. Trying out of various roles d. Conformity to group norms e. Preoccupied with rapid body changes ANS: C, D, E Characteristics of early adolescence identity include trying out of various roles, conformity to group norms, and preoccupation with rapid body changes. Mature sexual identity and increase in self-esteem are characteristics of late adolescent identity. DIF: Cognitive Level: Analyzing REF: MCS: 661 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 3. What are characteristics of middle adolescence (1517 years) with regard to relationships with peers? (Select all that apply.) a. Behavioral standards set by peer group b. Acceptance of peers extremely important c. Seeks peer affiliations to counter instability d. Exploration of ability to attract opposite sex e. Peer group recedes in importance in favor of individual friendship ANS: A, B, D Characteristics of middle adolescence relationships with peers include behavioral standards set by the peer group, acceptance of peers is extremely important, and exploration of the ability to attract opposite sex. Seeking peer affiliations to counter instability is a characteristic of early adolescence relationships with peers. Peer groups receding inpiomrtance in favor of individual friendships is characteristic of late adolescence relationships with peers. DIF: Cognitive Level: Analyzing REF: MCS: 652 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. What are characteristics of late adolescence (1820 years) with regard toistye?xu(Salelect a l l that apply.) a. Exploration of self-appeal b. Limited dating, usually group c. Intimacy involves commitment d. Growing capacity for mutuality and reciprocity e. May publicly identify as gay, lesbian, or bisexual ANS: C, D, E Characteristics of late adolescence sexuality dineclu intimacy involving commitment; growing capacity for mutuality and reciprocity; and publicly identifying as gay, lesbian, or bisexual. Exploration of self-appeal is a characteristic of middle adolescence sexuality.mLited da ting, usually group, is a characteristic of early adolescence sexuality. DIF: Cognitive Level: Analyzing REF: MCS: 652 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. What are characteristics of dating relationships in early adolescence? (Select all that apply.) a. One-on-one dating b. Follow ritualized scripts c. Are psychosocially intimate d. Involve playing stereotypic roles e. Participating in mixed-gender group activities ANS: B, D, E Early dating relationships typically follow highly rliztuead s cripts in cwhhai dolescents are me or likely to play steresothtyapnictororele ally be themselves. Participating in mixed-gender group activities, such as going to parties or other events, may have a positive impact on young teenagers well-being. One-on-one dating during early adolescence, however, with a lot of time spent alone, may lead to sexual intimacy before a teen is ready. Although teenagers may begin dating during early adolescence, these early dating relationships are not usually psychosocially intimate. DIF: Cognitive Level: Analyzing REF: MCS: 652 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 6. The school nurse recognizes that students who are targeted for repeated harassment and bullying may exhibit what? (Select all that apply.) a. Skip school b. Attempt suicide c. Bring weapons to school d. Attend extracurricular activities e. Report symptoms of depression ANS: A, B, C, E Students targeted for repeated teasing and harassment are more likely to skip school, to report symptoms of depression, and to attempt suicide. Equally troubling, teens who are regularly harassed or bullied are also morekelliy to bri ng weapons to school to feel safe. Students who are bullied do not want to attend extracurricular activities. DIF: Cognitive Level: Analyzing REF: MCS: 667 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 7. Parents of an adolescent ask the school nurse, It is OK for our adolescent to get a job? The nurse should answer telling the parents the effects of adolescents who work more than 20 hours a week are what? (Select all that apply.) a. Can lead to fatigue b. Can lead to poorer grades c. Improves an interest in school d. Enhances development and identity e. Can reduce extracurricular involvement ANS: A, B, E Detrimental effects are likely for adolescents who work more than 20 hours a week. Greater involvement in work can lead toifgaute, de creased interest in school,creedduext racurricular involvement, and poorer grades. Involvement in work meay take ti away from other activities that could contribute to identity development. Adolescent work as it exists today may negatively affect development. DIF: Cognitive Level: Applying REF: MCS: 667 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. An adolescent asks the nurse about the safety of getting a tattoo. The nurse explains to the adolescent that it is important to find a qualified operator using proper sterile technique because an unsterilized needle or contaminated tattoo ink can cause what? (Select all that apply.) a. Hepatitis C virus b. Hepatitis B virus c. Hepatitis E virus d. Human immunodeficiency virus (HIV) e. Mycobacterium chelonae skin infections ANS: A, B, D, E Using the same unsterilized needle to tattoo bodytps aorf lmtiuple teenagers presents the same risk for human immunodeficiency virus (HIV), hepatitis C virus, and hepatitis B virus transmission as occurs withdolteh-eshr anreie ng activities. Contaminated tattoo ink can cause nontuberculous M. chelonae skin infections. The hepatitis E virus is transmitted via the fecaloral route, principally via contaminated water, not by contaminated needles. DIF: Cognitive Level: Applying REF: MCS: 679 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 9. The school nurse teaches adolescents that the detrimental long-term effects of tanning are what? (Select all that apply.) a. Vitamin D deficiency b. Premature aging of the skin c. Exacerbates acne outbreaks d. Increased risk for skin cancer e. Possible phototoxic reactions ANS: B, D, E Adolescents should be educated regarding the detrimental effects of sunlight on the skin. Long- term effects include premature aging of the skin; increased risk for skin cancer; and, in susceptible individuals, phototoxic reactions. Exposure to levels of sunlight cause an increase in vitamin D production. Tanning can often reduce outbreaks of acne. DIF: Cognitive Level: Applying REF: MCS: 680 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. What guidelines should the nurse use when interviewing adolescents? (Select all that apply.) a. Ensure privacy. b. Use open-ended questions. c. Share your thoughts and assumptions. d. Explain that all interactions will be confidential. e. Begin with less sensitive issues and proceed to more sensitive ones. ANS: A, B, E Guidelines for interviewing adolescents include ensuring privacy, using open-ended questions, and beginning with less sensitive issues and proceeding to more sensitive ones. The nurse should not share thoughts but maintain objectivity and should avoid assumptions, judgments, and lectures. It may not be possible for all interactions to be confidential. Limits of confidentiality include a legal duty to report physical or sexual abuse and to get others involved if an adolescent is suicidal. Chapter 18.Health Problems of the Adolescent MULTIPLE CHOICE 1. Tretinoin (Retin-A) is a commonly used topical agent for the treatment of acne. What do nursing considerations with this drug include? a. Sun exposure increases effectiveness. b. Cosmetics with lanolin and petrolatum are preferred in acne. c. Applying of the medication occurs at least 20 to 30 minutes after washing. d. Erythema and peeling are indications of toxicity and need to be reported. ANS: C The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. The avoidance of sun and the use of sunscreen agents must be emphasized because sun exposure can result in severe sunburn. Cosmetics with lanolin, petrolatum, vegetable oil, lauryl alcohol, butyl stearate, and oleic acid can increase comedone production. Erythema and peeling are common local manifestations. DIF: Cognitive Level: Analyzing REF: MCS: 689 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 2. What is the usual presenting symptom for itceustlar cancer? a. Solid, painful mass b. Hard, painless mass c. Scrotal swelling and pain d. Epididymis easily palpated ANS: B The usual presenting symptom for testicular cancer is ad,heavy, har painless mass that is either smooth or nodular and palpated on the testes. Pain is not usually associated with a testicular tumor. Scrotal swelling needs to be evaluated. The epididymis is easily palpated in a normal scrotum. DIF: Cognitive Level: Understanding REF: MCS: 691 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 3. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action? a. Refer him for immediate medical evaluation. b. Administer analgesics and recommend scrotal support. c. Apply an ice bag and observe for increasing pain. d. Reassure the adolescent that occasional pain is common with the changes of puberty. ANS: A Any adolescent boy with redness, swelling, or pain in the scrotum is referred for immediate evaluation. These are signs of testicular torsion, which is a medical emergency. If the possibility of testicular torsion is eliminated, appropriate interventions include administering analgesics and recommending scrotal support. applying an ice bag and observing for increasing pain. and reassuring the adolescent that occasional pain is common with the changes of puberty. DIF: Cognitive Level: Applying REF: MCS: 693 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. A 14-year-old boy is of normal weight, and his parents are concerned about bilateral breast enlargement. The nurses discussion of this should be based on what? a. The presence of too much body fat b. Symptom that a hormonal imbalance is present c. Most likely part of normal pubertal development d. Indication that he is developing precocious puberty ANS: C Gynecomastia is common during midpuberty in about one third of boys. For most, the breast enlargement disappears within 2 years. Although breast enlargement in overweight children can indicate too much body fat, in children of normal body weight, it is a normal occurrence. If the gynecomastia persists beyond 2 years, then a hormonal cause may need to be investigated. Precocious puberty is the early onset of puberty, before age 9 years in boys. DIF: Cognitive Level: Applying REF: MCS: 693 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I5n. tAeg1ri5ty-year-old girl tells the school nurse that she has not started to menstruate yet. Onset of secondary sexual characteristics was about 2 1/2 years ago. The nurse should take which action? a. Explain that this is not unusual. b. Refer the adolescent for an evaluation. c. Make an assumption that the adolescent is pregnant. d. Suggest that the adolescent stop exercising until menarche occurs. ANS: B A referral is indicated. Menarche should follow the onset of secondary sexual development within 2 1/2 years. A careful examination is done to reveal any physical abnormalities, signs of androgen excess, and congenital defects of the genital tract. The lack of the onset of menstruation at this age is a potential indication of a physical problem. Assuming that the adolescent is pregnant is inappropriate. The nurse does not have any indication that the adolescent is sexually active. The amount of exercise should be assessed before suggesting that the adolescent stop exercising until menarche occurs. DIF: Cognitive Level: Applying REF: MCS: 694 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I6n. tAegnriatdyolescent girl asks the school nurse for advice because she has dysmenorrhea. She says that a friend recommended she try an over-the-counter nonsteroidal anti-inflammatory drug (NSAID). The nurses response should be based on what? a. Hormone therapy is necessary for the treatment of dysmenorrhea. b. Acetaminophen is the drug of choice for the treatment of dysmenorrhea. c. Over-the-counter NSAIDs are rarely strong enough to provide adequate pain relief. d. NSAIDs are effective because they inhibit prostaglandins, leading to reduction in uterine activity. ANS: D First-line therapy for adolescents with dysmenorrhea is NSAIDs. NSAIDs are potent anti- inflammatory agents that block the formation of prostaglandins, resulting in decreased uterine activity. Hormone therapy may be indicated if there is no physical abnormality and NSAIDs are ineffective. Acetaminophen does not have an antiprostaglandin action. It can help with pain control but will not be as effective as NSAIDs. DIF: Cognitive Level: Applying REF: MCS: 696 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I7n. tWeghriattyis a major physical risk for young adolescents during pregnancy? a. Osteoporosis frequently develops. b. Fetopelvic disproportion is a common problem. c. Delivery is usually precipitous in this age group. d. Pregnancy will adversely affect the adolescents development. ANS: B Teenagers younger than 15 years of age have increased obstetric risks. Fetopelvic disproportion is one of the most common complications. Osteoporosis occurs later in life and is not related to adolescent pregnancy. Prolonged, not precipitous, labor is common in this age group. Teenage mothers are socially, educationally, psychologically, and economically disadvantaged. Support is necessary because the tasks of motherhood are superimposed on adolescent development tasks. DIF: Cognitive Level: Understanding REF: MCS: 718 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. The nurses role ilnitaftaicnig successful dchreilaring in unmarried teenage mothers includes what? a. Facilitating marriage between the mother and father of the baby b. Teaching the adolescent the long-term needs of the growing child c. Providing information and feedback about positive parenting skills d. Encouraging the infants grandmother to take responsibility for care ANS: C Competence in a teenage mother is increased when feedback is provided about positive parenting skills and use of community resources. The nurse can identify and refer the mother to programs such as support groups for adolescent mothers, infant stimulation programs, and parenting programs. Facilitating marriage between the mother and the father of the baby may produce additional stress and detract from their ability to care for the infant. Encouraging the infants grandmother to take responsibility for care would decrease the mothers ability to develop successful childrearing behaviors. Supportive families can provide assistance tole tahbe teenage mother toecoscmhpoloelt. Many adolescents do not have a future perspective for themselves. The nurse includes information on normal infant development to aid the mother in having reasonable expectations. DIF: Cognitive Level: Analyzing REF: MCS: 719 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 9. What is a priority goal in the postpartum care of an adolescent mother? a. Prevention of subsequent pregnancies b. Ensuring that the father of the baby cares for the child c. Returning the mother to a prepregnancy lifestyle d. Facilitating formula feeding to minimize interruptions ANS: A Postpartum care of the adolescent is directed at preventing subsequent pregnancies and enhancing life outcomes for the teen parents and child. Health care programs should provide comprehensive contraceptive services at the same time the child is seen for appointments. Ensuring the father of the baby cares for the child is not part of the postpartum care of the mother. The adolescent mother cannot return to a prepregnancy lifestyle. She now has an infant to care for. Breastfeeding is recommended for the infant. The nurse and mother should explore the best nutrition for both the mothers needs and those of the infant. DIF: Cognitive Level: Analyzing REF: MCS: 721 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 10. A pregnant 15-year-oldeasdcoelnt tells the sneurtha t she did not use any form of contraception because she was afraid her parents would find out. The nurse should recognize what? a. This is a frequent reason given by adolescents. b. This suggests a poor parentchild relationship. c. This is not a good reason to not get contraception. d. This indicates that the adolescent is unaware of her legal rights. ANS: A This is one of the most common reasons given by teenagers for not using contraception. Although it is optimum for the parents to be involved in the health care of adolescents, some adolescents require confidential care. Privacy is important as they develop their personal identity and establish relationships. The adolescent may be concerned about parental judgment. The adolescent should discuss with the health care provider contraception that meets her needs; some of the longer acting birth control methods may be preferable. The adolescent did not tell the nurse that she was unaware that she could legally obtain contraceptive materials; she was concerned about her parents. DIF: Cognitive Level: Understanding REF: MCS: 722 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 11. An adolescent girl calls the nurse at ethclinic becaus e she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain? a. It is too late to prevent an unwanted pregnancy. b. An abortion may be the best option if she is pregnant. c. The risk of pregnancy is minimal, so no action is necessary. d. Postcoital contraception is available to prevent implantation and therefore pregnancy. ANS: D Several emergency methods of contraception (ECP) are available and appropriate for use after unprotected sexual intercourse. A progestin-only ECP (levonorgestrel [Plan B]) is approved by the U.S. Food and Drug Administration and has high effectiveness and low rates of side effects. Plan B is effective if given within 72 hours of unprotected intercourse. An abortion is not indicated. Although the risk of pregnancy depends on the time during her menstrual cycle, a low risk of pregnancy exists. ECP is indicated. DIF: Cognitive Level: Understanding REF: MCS: 725 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 12. An adolescent girl is brought to the hospital emergency department by her parents after being raped. The girl is calm and controlled throughout the interview and examination. The nurse should recognize this behavior is what? a. A sign that a rape has not actually occurred b. One of a variety of behaviors normally seen in rape victims c. Indicative of a higher than usual level of maturity in the adolescent d. Suggestive that the adolescent had severe emotional problems before the rape occurred ANS: B Rape victims display a wide range of behaviors. A controlled manner may be an attempt to maintain composure while hiding the inner turmoil. Because the observed behavior is within the range of expected behavior, there are no data to indicate that a rape has not actually occurred, that the adolescent is unusually mature, or atht s he had severe emotional problems before the rape occurred. DIF: Cognitive Level: Analyzing REF: MCS: 726 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 13. The nurse has determined that an adolescents body mass index (BMI) is in the 90th percentile. What information should the nurse convey to the adolescent? a. The adolescent is overweight. b. The adolescent has maintained weight within the normal range. c. The adolescent is at risk for becoming overweight. d. Nutritional supplementation should occur at least three times per week ANS: C Adolescents with BMIs between the 85th and 94th percentile for age and gender are at risk for becoming overweight. Adolescents with BMIs greater than the 95th percentile are classified as overweight. Nutritional guidance, not supplementation, is needed. DIF: Cognitive Level: Applying REF: MCS: 727 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 14. The nurse is teaching a class on obesity prevention to parents in the community. What is a contributing factor to childhood obesity? a. Birth weight b. Parental overweight c. Age at the onset of puberty d. Asian ethnic background ANS: B There is a high correlation between parental adiposity and childhood adiposity. Obese children do not have higher birth weights than nonobese children. Early menarche is associated with obesity, but the age of puberty is not a contributing factor. African Americans and Hispanics have disproportionately high percentages of overweight individuals, but Asians do not. DIF: Cognitive Level: Understanding REF: MCS: 731 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 15. During a well-child visit, the nurse spltohte purpose of the BMI? lcdhsi IBoMn the lhteharecord. What is the a. To determine medication dosages b. To predict adult height and weight c. To identify coping strategies used by the child d. To provide a consistent measure of obesity ANS: D A consistent measure of the degree of obesity is important to determine whether modification of the body fat component is indicated. Body surface area (BSA), not BMI, is used for medication dosage calculation. The BMI is not a predictor of adult height. A child with a high BMI may use food as a coping mechanism, but the BMI is not correlated with coping strategy use. DIF: Cognitive Level: Applying REF: MCS: 733 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 16. During a well-child visit, the nurse practitioner provides guidance about promoting healthy eating in a child who is overweight. What does the nurse advise? a. Slow down eating meals. b. Avoid between-meal snacks. c. Include low-fat foods in meals. d. Use foods that child likes as special treats. ANS: A When a child slows down the eating process, it is easier to recognize signs of fullness. If food is consumed rapidly, itsh feedback i s lost. Regular meals and snacks are encouraged to prevent the child from becoming too hungry and overeating. Low-fat foods are usually higher in calories than the regular versions. Nutritional labels should be checked and foods high in sugar and calories avoided. Food should not be used as a special treat or reward; this encourages the child to use food as comfort measures in response to boredom and stress. DIF: Cognitive Level: Applying REF: MCS: 733 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 17. The middle school ns uprlsaeni ning a behavior modification program for overweight children. What is the tmiomsportant goal for participants of the apmro?gr a. Learn how to cook low-fat meals. b. Improve relationships with peers. c. Identify and eliminate inappropriate eating habits. d. Achieve normal weight during the program. ANS: C The goal of behavior modification in weight control is to help the participant identify abnormal eating processes. After the abnormal patterns are identified, then techniques, including problem solving, are taught to eliminate inappropriate eating. Learning how to cook low-fat meals can be a component of the program, but the focus of behavior modification is identifying target behaviors that need to be changed. Improving relationships is not the focus of weight management behavior management programs. Achieving normal weight during the program is an inappropriate goal. As the child incorporates the techniques, weight gain will slow. In childhood obesity, the goal is to stop the increase of weight gain. DIF: Cognitive Level: Applying REF: MCS: 734 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 18. Descriptions of young people with anorexia nervosa (AN) often include which criteria? a. Impulsive b. Extroverted c. Perfectionist d. Low achieving ANS: C Individuals with AN are described as striving for perfection, which may manifest in other compulsive disorders. They are also academically high achievers. Impulsive and extroverted personalities are more characteristic of bulimia nervosa. DIF: Cognitive Level: Applying REF: MCS: 737 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 19. What behavior is the onsutrsle m (AN)? ikely to assess in an adolescent with anorexia nervosa a. Eats in secrecy b. Uses food as a coping mechanism c. Has a marked preoccupation with food d. Lacks awareness of how eating affects weight loss ANS: C Individuals with AN display great interest in food. They prepare meals for others, talk about food, and hoard food. During meals, food play may occur to appear as if the person is eating. Persons with AN consume a small amount of food, so they have no need to eat in secrecy. Individuals with bulimia nervosa (BN) usually binge privately. Food is not used as a coping mechanism in AN, as is common in BN. Individuals with AN know about the relationship between calorie intake and calorie expenditure. They can regulate intake and then exercise to not gain or to lose weight. DIF: Cognitive Level: Applying REF: MCS: 738 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Psychosocial Integrity 20. During the physical examination of an adolescent with significant weight loss, what finding may indicate an eating disorder? a. Diarrhea b. Amenorrhea c. Appetite suppression d. Erosion of tooth enamel ANS: D Some of the signs of bulimia include erosion of tooth enamel and increased dental caries. Check the back of the hands for abrasions caused by rubbing against the maxillary incisors during self- induced vomiting. Diarrhea is not a result of vomiting. Rather, it may occur in patients with inflammatory bowel disease and other gastrointestinal diseases. Amenorrhea can occur with anorexia nervosa, but it can also be a result of the weight loss from other causes. It can also indicate pregnancy intafdolescen emales. Appetite suppression can occur from central vnoerus system lesions or from oncologic and metabolic disorders. DIF: Cognitive Level: Analyzing REF: MCS: 740 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 21. What goal is most important when caring for a child with anorexia nervosa (AN)? a. Limit fluid intake. b. Prevent depression. c. Correct malnutrition. d. Encourage weight gain. ANS: C In children diagnosed with AN or bulimia nervosa, the priority consideration is to correct the malnutrition. Severe malnutrcittiroonly, eteled isturbances, vital sign abnormalities, and psychiatric disorders may be present. Careful monitoring is necessary to avoid complications. Often fluid kineta is restricted by individuals with AN. Fluid balance must be restored. Preventing depression is important, but the correction of potentially life-threatening malnutrition takes precedence.tAerft he initial malnutrition is corrected, then a plan is established for nutritional therapy. DIF: Cognitive Level: Analyzing REF: MCS: 741 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 22. What do nursing responsibilities regarding weight gain for an adolescent with anorexia nervosa include? a. Administer tube feedings until target weight is achieved. b. Restore body weight to within 10% of the adolescents ideal weight. c. Encourage continuation of strenuous exercise as long as adolescent is not losing weight. d. Facilitate as rapid a weight ngaai s possible with a high-calorie diet. ANS: B The restoration of body weight to a target weight or endpoint within 10% of ideal body weight is one of the main goals of therapy. Strenuous exercise is avoided as part of the need to modify behaviors. Tube feedings are intrusive and are avoided. They should only be used when other measures have failed. Weight restoration is accomplished slowly. The goal is 1 kg/wk to avoid the risk of metabolic and cardiac problems. Slow weight gain can minimize anxiety and depression. DIF: Cognitive Level: Analyzing REF: MCS: 741 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23. An important distinction in understanding substance abuse is that drug misuse, abuse, and addiction are considered what? a. Voluntary behaviors based on psychosocial needs b. Problems that occur in conjunction with addiction c. Involuntary physiologic responses to the pharmacologic characteristics of drugs d. Legal use of substances for purposes other than medicinal. ANS: A Drug misuse, abuse, and addiction are considered voluntary behaviors. Cultural norms define what is abuse and misuse. Addiction is a psychologic dependence on a substance with or without physical dependence. Physical dependence is an involuntary response to the pharmacologic characteristics of the drug such as an opiate or alcohol. Legality is not always a factor in substance abuse. Legal substances such as alcohol and tobacco can also be misused or abused and can cause addiction. DIF: Cognitive Level: Applying REF: MCS: 745 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 24. What statement is true about smoking in college students? a. The rate of smoking cigarettes is declining. b. Smokeless tobacco use is rising dramatically. c. Regular cigar use is becoming more common. d. Students in the health professions do not smoke. ANS: C Approximately 8.5% of college students smoke cigars on a regular basis. Among college students, the rate of acrigette smoking is ri sing. At last report, 28.5% of this group smoked cigarettes. Use of smokeless tobacco is declining overall. Students in the health professions do smoke. DIF: Cognitive Level: Applying REF: MCS: 746 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 25. What strategy is considered one of the best for preventing smoking in teenagers? a. Large-scale printed information campaigns b. Emphasis on the long-term effects of smoking on health c. Threatening the social norms of groups most likely to smoke d. Peer-led programs emphasizing the social consequences of smoking ANS: D Peer-led programs emphasizing the social consequences of smoking have proved most successful. Short-term effects such as an unpleasant odor and stains on the teeth and hands are stressed. If a significant number of peers convince their classmates that smoking is not popular, others will follow. Large-scale printed information campaigns are not effective. A specified curriculum and teaching can increase benefit. Long-term effects do not dissuade adolescents because they do not have a future perspective. Threatening the norms of the social group is one of the least effective means of prevention. DIF: Cognitive Level: Applying REF: MCS: 747 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 26. Many adolescents use alcohol for mseelfd-ication. How does an adolescent view the benefit of alcohol? a. Believes it has a stimulant effect b. Believes it increases alertness c. Provides a sense of euphoria d. Provides a defense against depression ANS: D Adolescents who abuse alcohol often rely on it as a defense against depression, anxiety, fear, and anger. Alcohol eisparedssant and has a sedative effect. Alcohol does not provide a sense of euphoria. It does reduce inhibitions against aggressive behaviors. DIF: Cognitive Level: Understanding REF: MCS: 747 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 27. What factor is tmloiksely torienacse th e likelihood that an adolescent will misuse alcohol? a. Female gender b. Regular school attendance c. Rural environment d. Unconventional behavior ANS: D Adolescents who are connected and engage in conventional behavior are less likely to misuse alcohol. Those who are disconnected from school, family, and other social supports have fewer assets and are more likely tolacbouhsoel.aS chool eanttdance is a sign of connectedness.rGlsi and boys report a similar onset and course of experimentation with alcohol. Urban youths have a higher likelihood of alcohol abuse than rural adolescents. DIF: Cognitive Level: Applying REF: MCS: 747 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 28. What best describes central nervous system N(CS) st imulants? a. Acute intoxication can lead to coma. b. They produce strong physical dependence. c. Withdrawal symptoms are life threatening. d. They can result in strong psychologic dependence. ANS: D CNS stimulants such as amphetamines and cocaine produce a strong psychologic dependence. Acute intoxication leads to violent vagegbrehssaivior cohr optsiy c episodes characterized by paranoia, uncontrollable agitation, and restlessness. This class of drugs does not produce strong physical dependence and can be withdrawn without much danger. DIF: Cognitive Level: Understanding REF: MCS: 748 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 29. The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection by the nurse should include what information? a. Drugs actual content b. Mode of administration c. Adolescents level of interest in rehabilitation d. Function the drug plays in the adolescents life ANS: B Cocaine is available in two forms, water soluble and nonwater soluble, and can be administered through multiple routes. eFaotrmtrent purposes, it is essential to know the type of drug and route of administration. Because cocaine is a street drug, the actual content lulsua y cannot be identified. The adolescents level of interest in rehabilitation and the function that drug plays in the adolescents life are concerns to be addressed after the initial emergency treatment is instituted. DIF: Cognitive Level: Applying REF: MCS: 748 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 30. What statement risuet concerning eandtolesc suicide? a. A sense of hopelessness and despair is a normal part of adolescence. b. Gay and lesbian adolescents are at a particularly high risk for suicide. c. Problem-solving skills are of limited value to the suicidal adolescent. d. Previous suicide attempts are not an indication for completed suicides. ANS: B A significant number of teenage suicides occur among homosexual youths. Gay and lesbian adolescents who live in families or communities that do not accept homosexuality are likely to experience low self-esteem, self-loathing, depression, and hopelessness. Most adolescents do not experience this stage of life as a time of despair. Depressive symptoms, acting-out behaviors, and talk of suicide need to be taken seriously. At-risk teenagers include those who are depressed, have poor problem-solving skills, or use drugs and alcohol. A history of a previous suicide attempt is a serious indicator for possible suicide completion in the future. DIF: Cognitive Level: Understanding REF: MCS: 751 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 31. What method is the most commonly used in completed suicides? a. Firearms b. Drug overdose c. Self-inflicted laceration d. Carbon monoxide poisoning ANS: A Firearms are the most commonly used instruments in completed suicides among both males and females. For completed suicides in adolescent boys, firearms are followed by hanging and overdose. For adolescent girls, overdose and strangulation are the next most common means of completed suicide. The most common method of suicide attempt is overdose or ingestion of potentially toxic substances such as drugs. The second most common method of suicide attempt is self-inflicted laceration. Carbon monoxide poisoning is not one of the more frequent forms of suicide completion. DIF: Cognitive Level: Understanding REF: MCS: 751 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 32. What is the most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats? a. Level of stress b. Social isolation c. Degree of depression d. Desire to punish others ANS: B Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who will not. It is also more characteristic of those who complete suicide versus those who make attempts or threats. Although the level of stress, the degree of depression, and the desire to punish others are contributing factors in suicide, they are not the most significant factor in distinguishing those who complete suicide from those who attempt suicide. DIF: Cognitive Level: Understanding REF: MCS: 752 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 33. An adolescent girl tells the nurse that she is very suicidal. The nurse asks her if shae ha specific plan. How should asking about a specific plan be viewed? a. Not a critical part of the assessment b. An appropriate part of the assessment c. Suggesting that adolescent needs a plan d. Encouraging adolescent to devise a plan ANS: B Routine health assessments of adolescents should ilundce questions that assess the presence of suicidal ideation or intent. Questions such as Have you ever developed a plan to hurt yourself or kill yourself? should be part of that assessment. Adolescents who express suicidal feelings and have a specific plan are at particular risk and require further assessment and constant monitoring. The information about having a plan is an essential part of the assessment and greatly affects the treatment plan. DIF: Cognitive Level: Understanding REF: MCS: 752 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 34. The nurse is presenting an educational program to a group of parents about differences between anorexia nervosa (AN) and bulimia nervosa (BN) at a community outreach program. What statement by a parent would indicate a need for additional teaching? a. A child with AN will turn away from food to cope, but a child with BN turns to food to cope. b. A child with AN maintains rigid control and is introverted, but a child with BN is an extrovert and frequently loses control. c. A child with AN denies the illness, but a child with BN recognizes the illness. d. A child with AN is usually sexually active and seeks intimacy, but a child with BN avoids intimacy and is usually not sexually active. ANS: D A child with AN is usually the one who avoids intimacy and is not sexually active, but a child BN often seeks intimacy and is sexually active. A child with AN turns away from food to cope with life, maintains rigid control, is introverted, and denies the illness. A child with BN turns to food to cope, is an extrovert who loses control, and recognizes that he or she has an illness. DIF: Cognitive Level: Applying REF: MCS: 740 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I3n5t.eTgrhietynurse is teaching an adolescent about acne care. What statement by the adolescent indicates a need for further teaching? a. I will cleanse my face twice a day. b. I will frequently shampoo my hair. c. I will brush my hair away from my forehead. d. I will use my antibacterial soap to cleanse my face. ANS: D Antibacterial soaps are ineffective and may be drying when used in combination with topical acne medications. Further teaching is needed if the adolescent indicates using antibacterial soap. Gentle cleansing with a mild cleanser once or twice daily is usually sufficient. For some adolescents, hygiene of the hair and scalp appears to be related to the clinical activity of acne. Acne on the forehead may improve with brushing the hair away from the forehead and more frequent shampooing. DIF: Cognitive Level: Applying REF: MCS: 688 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Health Promotion and Maintenance 36. After a treatment plan for acne has been initiated, which time period should the nurse explain to an adolescent before improvement will be seen? a. 2 to 4 weeks b. 4 to 6 weeks c. 6 to 8 weeks d. 8 to 10 weeks ANS: C Inform patients that after a treatment plan for acne has bene appreciate improvement in their skin. DIF: Cognitive Level: Applying REF: MCS: 690 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance initiated, it will take 6 to 8 weeks to 37. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take? a. Place a warm moist pack on the scrotal area. b. Instruct the adolescent to lie down and elevate the legs. c. Refer the adolescent for immediate medical evaluation. d. Suggest that the adolescent wear a scrotum-protecting guard. ANS: C Because torsion may result from trauma to the scrotum, school nurses are likely to encounter such injuries and should refer the child or adolescent for medical evaluation immediately. It would not be appropriate to apply warmth, elevate the legs, or tell the adolescent to wear a scrotum-protecting guard because these actions could delay treatment. DIF: Cognitive Level: Applying REF: MCS: 693 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 38. The clinic nurse is evaluating aneasdcoelnt w ith menses that have stopped occurring. The nurse understands that which minimum amount of time should the menses be absent after a period of menstruation to be diagnosed as secondary amenorrhea? a. 3 months b. 4 months c. 5 months d. 6 months ANS: D A 6-month or more cessation of menses after a period of menstruation is secondary amenorrhea. DIF: Cognitive Level: Understanding REF: MCS: 694 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 39. An adolescent patient ehnasdbiaegnosed with a vulvovaginal candidiasis (yeast infection). The nurse expects the health care provider to recommend which vaginal cream? a. Premarin b. Estradiol (Estrace) c. Miconazole (Monistat) d. Clindamycin phosphate (Cleocin) ANS: C A number of antifungal preparations are available for the treatment of vulvovaginal candidiasis infections. Many of these medications (e.g., miconazole [Monistat] and clotrimazole [Gyne- Lotrimin]) are available as over-the-counter (OTC) agents. Premarin and Estrace are estrogen vaginal creams and are used to treat vaginal dryness. Cleocin is an iabnatcterial va ginal cream used to treat bacterial vaginal infections. DIF: Cognitive Level: Analyzing REF: MCS: 704 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 40. A sexually active adolescent asks the school nurse about epvr ention of sexually transmitted infections (STIs). What should the nurse recommend? a. Use of condoms b. Prophylactic antibiotics c. Any type of contraception method d. Withdrawal method of contraception ANS: A When used appropriately, condoms provide a barrier to the organisms that cause STIs. Prophylactic antibiotics are not recommended; they are effective only against bacteria, not viruses. Only condoms create a physical barrier that prevents contact with the organisms. DIF: Cognitive Level: Understanding REF: MCS: 704 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment 41. What statement is true agboonuotrrhea? a. It is caused by Treponema pallidum. b. Treatment of all sexual contacts is essential. c. Topical application of medication to the lesions is necessary. d. Therapeutic management includes multidose administration of penicillin. ANS: B The treatment plan should include finding and treating all sexual partners. Gonorrhea is caused by Neisseria gonorrhoeae. Syphilis is caused by T. pallidum. Systemic therapy is necessary to treatseth. iPs dis rimary tretma ent is w ith fdeifrent antibiotics be cause of N. gonorrhoeaes resistance to penicillin. DIF: Cognitive Level: Understanding REF: MCS: 707 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 42. What statement rdeginag chlamydial infections is correct? a. The treatment of choice is oral penicillin. b. The treatment of choice is nystatin or miconazole. c. Both men and women may have asymptomatic infections. d. Clinical manifestations include small, painful vesicles on the genital areas. ANS: C The incidence of asymptomatic chlamydial infections is as high as 50% of men and 75% of women. Symptoms of chlamydial infection in men include meatal erythema, tenderness, itching, dysuria, and urethral discharge. Oral penicillin, nystatin, and miconazole are not the antibiotics of choice. Small, painful vesicles on genital areas are clinical manifestations of herpetic infections. DIF: Cognitive Level: Understanding REF: MCS: 706 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 43. What is true about pelvic inflammatory disease (PID)? a. It can be prevented by proper personal hygiene. b. It is easily prevented by compliance with any form of contraception. c. It may have devastating effects on the reproductive tract of affected adolescents. d. It can potentially cause life-threatening and serious defects in the future children of affected adolescents. ANS: C PID is a major rcnonbce ecause of its devastating effects on the reproductive tract. Short-term complications include abscess formation in the fallopian tubes, and long-term complications include ectopic pregnancy, infertility, and dyspareunia. PID is an infection of the upper female genital tract, most commonly caused by sexually transmitted infections. Personal hygiene, oral contraceptives, and many other forms of contraception do not prevent transmission of the disease. There is a possibility of ectopic pregnancy but not birth defects in children. DIF: Cognitive Level: Analyzing REF: MCS: 710 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 44. It is important that women with anogenital warts caused by the human papillomavirus (HPV) receive adequate treatment because this sexually transmitted infection increases the risk of what? a. Gonorrhea b. Cervical cancer c. Chlamydial infection d. Urinary tract infection ANS: B Infection with HPV is associated with cervical dysplasia and cervical cancer. A vaccine has been developed and is recommended for young women. DIF: Cognitive Level: Analyzing REF: MCS: 712 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 45. The clinic nurse is evaluating a patient with a vaginal infection. The nurse knows that the normal vaginal pH is in which range? a. 3.0 to 4.0 b. 4.0 to 5.0 c. 5.0 to 6.0 d. 6.0 to 7.0 ANS: B Normal vaginal secretions are acidic, with a pH range of 4.0 to 5.0. DIF: Cognitive Level: Analyzing REF: MCS: 704 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. What conditions are physical complications of obesity? (Select all that apply.) a. Type 2 diabetes mellitus b. QT interval prolongation c. Fatty liver disease d. Gastrointestinal dysfunction e. Abnormal growth acceleration f. Dental erosion ANS: A, C, E Physical complications of obesity include type 2 diabetes mellitus, which is reaching epidemic proportions in children and adolescents; fatty liver disease not related to alcohol consumption; and abnormal growth acceleration in which overweight children tend to be taller and mature earlier than children who are not overweight. Prolonged QT intervals, gastrointestinal dysfunction, and dental erosion are physical complications observed in children or adolescents who have eating disorders such as anorexia nervosa or bulimia. DIF: Cognitive Level: Applying REF: MCS: 731 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. The nurse is teaching an adolescent about the use of tretinoin (Retin-A). What should the nurse include in the teaching session? (Select all that apply.) a. Begin with a pea-sized dot of medication. b. Apply additional medication to the throat. c. Use sunscreen daily and avoid the sun when possible. d. Divide the medication into the three main areas of the face. e. Apply the medication immediately after washing the face. ANS: A, C, D Tretinoin is available as a cream, gel, iodr.liqu This dnrbueg ca reexmt ely irr itating to the nski and requires careful patient education for optimal usage. The patient should be instructed to begin with a pea-sized dot of medication, which is divided into thr ee main areas of the face and then gently rubbed into each area. The avoidance of the sun and the daily use of sunscreen must be emphasized because sun exposure can result in severe sunburn. The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. The medication should not be applied to the throat. DIF: Cognitive Level: Applying REF: MCS: 689 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. The clinic nurse is assessing antaodnolescen a topical antibacterial agent. The nurse should assess for which side effects that can be seen with topical antibacterial agents? (Select all that apply.) a. Burning b. Dryness c. Dry eyes d. Erythema e. Nasal irritation ANS: A, B, D Side effects of topical antibacterial medications include erythema, dryness, and burning; using the medications every other day will decrease the adverse effects. Dry eyes and nasal irritation are seen with use of isotretinoin, 13-cis-retinoic acid (Accutane). DIF: Cognitive Level: Applying REF: MCS: 689 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. What are risk factors of testicular cancer? (Select all that apply.) a. Hispanic b. Infertility c. Alcohol use d. Tobacco use e. Family history ANS: B, D, E Risk factors of testicular cancer include infertility, tobacco use, and a family history. White, not Hispanic, ethnicity is a high risk, and alcohol use is not a risk. Chapter 19.Impact of Chronic Illness, Disability, or End of Life Care for the Child and Family MULTIPLE CHOICE 1. What is the major health concern of children in the United States? a. Acute illness b. Chronic illness c. Congenital disabilities d. Nervous system disorders ANS: B An estimated l1d8r%enoinf cth e tUesnihtead Sta ve a chronic illness or disability that warrants health ecasrervices beyond those usually required by children. Chronic illness has surpassed acute illness as the major health concern for children. Congenital disabilities exist from birth but may not be hereditary. These represent a portion of the number of children with chronic illnesses. Mental and nervous system disorders account for approximately 17% of chronic illnesses in children. DIF: Cognitive Level: Understanding REF: MCS: 761 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 2. What is a major premise of family-centered care? a. The child is the focus of all interventions. b. Nurses are the authorities in the childs care. c. Parents are the experts in caring for their child. d. Decisions are made for the family to reduce stress. ANS: C As parents become increasingly responsible for lthdreeirn,cht i hey are the experts. It is essential that the health ceame rtecognize the familys expertise. I niflyam -centered care, consistent attention is given to the effects of the lcdhsi c hronic illness on all family members, not just the child. Nurses are adjuncts in the childs care. The nurse builds alliances with parents. Family members are involved in decision making about the childs physical care. DIF: Cognitive Level: Analyzing REF: MCS: 762 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 3. What should the nurse determine to be othreitypriintervention for a family with an infant who has a disability? a. Focus on the childs disabilities to understand care needs. b. Institute age-appropriate discipline and limit setting. c. Enforce visiting hours to allow parents to have respite care. d. Foster feelings of competency by helping parents learn the special care needs of the infant. ANS: D It is important that the parents learn how to rcea for the ir infant so they feel competent. The nurse facilitates this by teaching special holding techniques, supporting breastfeeding, and encouraging frequent visiting and rooming in. The focus should be on the infants capabilities and positive features. Infants do not usually require discipline. As the child gets older, this is necessary, but it is not a priority intervention at this time. The nursing staff negotiates with the family about the need for respite care. DIF: Cognitive Level: Analyzing REF: MCS: 763 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 4. The potential effects of chronic illness or disability on a childs development vary at different ages. What developmental alteration is a threat to a toddlers normal development? a. Hindered mobility b. Limited opportunities for socialization c. Childs sense of guilt that he or she caused the illness or disability d. Limited opportunities for success in mastering toilet training ANS: A Toddlers are acquiring a sense of autonomy, developing self-control, and forming symbolic representation through language acquisition. Mobility is the primary tool used by toddlers to experiment with maintaining control. Loss of mobility can ecrate a sens e of helplessness. Toddlers do not socialize. They are sensitive to changes in family routines. A sense of guilt is more likely to occur in a preschooler. Toilet training is not usually mastered until the end of the toddler period. DIF: Cognitive Level: Understanding REF: MCS: 768 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 5. A feeling of guilt that the child caused the disability or illness is especially common in which age group? a. Toddler b. Preschooler c. School-age child d. Adolescent ANS: B Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or disability or are being punished for wrongdoings. eToddlers ar focused on establishing their autonomy. The illness fosters dependency. School-age children have limited opportunities for achievement and may not be able to understand limitations. Adolescents face the task of incorporating their disabilities into their changing self-concept. DIF: Cognitive Level: Understanding REF: MCS: 769 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 6. What intervention is most appropriate for fostering the development of a school-age child with disabilities associated twhicer ebral palsy? a. Provide sensory experiences. b. Help develop abstract thinking. c. Encourage socialization with peers. d. Give choices to allow for feeling of control. ANS: C Peer interaction is especially important in relation to cognitive development, social development, and maturation. Cognitive development is facilitated by interaction with peers, parents, and teachers. The identification with those outside the family helps the child fulfill the striving for independence. Sensory experiences are beneficial, especially for younger children. School-age children are too young for abstract thinking. Giving school-age children choices is always an important intervention. Providing structured choices allows for a feeling of control. DIF: Cognitive Level: Applying REF: MCS: 763 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 7. A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. What should the nurse explain to his parents? a. That he needs more discipline b. That this is a normal part of adolescence c. That he needs more socialization with peers d. That this is how he is asking for more parental control ANS: B Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence, during which young adults are establishing independence. If the parents increase the amount of discipline, he will most likely be more rebellious. eMsoorcialization with peers does not saddres the problem of risk-taking behavior. DIF: Cognitive Level: Applying REF: MCS: 767 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. What nursing intervention is most appropriate in promoting normalization in a school-age child with a chronic illness? a. Give the child as much control as possible. b. Ask the childs peer to make the child feel normal. c. Convince the child that nothing is wrong with him or her. d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings. ANS: A The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child should be given as much control as possible. It is unrealistic for one individual to make the child feel normal. The child has a chronic illness, so it would be unacceptable to convince the child that nothing is wrong. The family rules should be similar for each of the lcdhrien in a family. Resentment and hostility can arise if different standards are applied to each child. DIF: Cognitive Level: Applying REF: MCS: 769 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse should recognize that this is most likely an indication that the child is experiencing what emotional response? a. Hopefulness b. Chronic sorrow c. Belief that procedures are a deserved punishment d. Understanding that procedures indicate impending death ANS: C The nurse should be particularly alert to a child who withdraws and passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment for being less worthy. A child who is hopeful is mobilized into goal-directed actions. This child would actively participate in care. Chronic sorrow is the feeling of sorrow santhdaltorsecurs in w aves over time. It is usually evident in the parents, not in the child. The seriously ill child would actively participate in care. Nursing interventions should be used to minimize the pain. DIF: Cognitive Level: Analyzing REF: MCS: 774 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. The parents of a child born with disabilities ask the nurse for advice about discipline. The nurses response should be based on remembering that discipline is which? a. Essential for the child b. Not needed unless the childs behavior becomes problematic c. Best achieved with punishment for misbehavior d. Too difficult to implement with a special needs child ANS: A Discipline is essential for the child. It provides boundaries on which she can test out her behavior and teaches her socially acceptable behaviors. The nurse should teach the parents ways to manage the childs behavior before it becomes problematic. Punishment is not effective in managing behavior. DIF: Cognitive Level: Applying REF: MCS: 777 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 11. Parents ask for help for their other children to cope with the changes in the family resulting from the special needs of their sibling. What strategy does the nurse recommend? a. Explain to the siblings that embarrassment is unhealthy. b. Encourage the parents not to expect siblings to help them care for the child with special needs. c. Provide information to the siblings about the childs condition only as requested. d. Invite the siblings to attend meetings to develop plans for the child with special needs. ANS: D Siblings should be invited to attend meeting to be part of the care team for the child. They can learn about an individualized education plan and help design strategies that will work at home. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner without punishing the sibling. The parents may need assistance with the care of the child. Most siblings are positive about tehxetra responsibilities. Parents need to inform the siblings about the childs condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is wrong with the child. DIF: Cognitive Level: Analyzing REF: MCS: 780 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 12. The nurse is assessing the coping behaviors of the parents of a child recently diagnosed with a chronic illness. What behavior should the nurse consider an approach behavior that results in movement toward adjustment? a. Being unable to adjust to a progression of the disease or condition b. Anticipating future problems and seeking guidance and answers c. Looking for new cures without a perspective toward possible benefit d. Failing to recognize the seriousness of the childs condition despite physical evidence ANS: B The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. These are positive actions in caring for their child. Being unable to adjust, looking for new cures, and failing to recognize the seriousness of the childs condition are avoidance behaviors. The parents are moving away from adjustment or exhibiting maladaptation to the crisis of a child with chronic illness or disability. DIF: Cognitive Level: Analyzing REF: MCS: 783 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 13. What nursing intervention is especially helpful in assessing feelings of parental guilt when a disability or chronic illness is diagnosed? a. Ask the parents if they feel guilty. b. Observe for signs of overprotectiveness. c. Talk about guilt only after the parents mention it. d. Discuss the meaning of the parents religious and cultural background. ANS: D Guilt may be associated withucrualltor irgeliou s beliefs. Some parents are ecdontvhiantcthey are being dpufnishe or some previous misdeed. Others may see the disorder as a trial sent by God to test their religious ibeefls. The nurse can help the parents explore their religious beliefs. On direct questioning, the parents may not be able to identify the feelings of guilt. It would be appropriate for the nurse to reexpthloeir ad justment nressepso. O verprotectiveness is a parental response during the adjustment phase. The parents fear letting the child achieve any new skill and avoid all discipline. DIF: Cognitive Level: Analyzing REF: MCS: 784 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 14. Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by what response? a. Denial b. Guilt and anger c. Social reintegration d. Acceptance of the childs limitations ANS: B For most families, the adjustment phase is accompanied by several responses, including guilt, self-accusation, bitterness, and anger. The initial diagnosis of a chronic illness or disability often is met with intense emotion and characterized by shock and denial. Social reintegration and acceptance of the childs limitations are the culmination of the adjustment process. DIF: Cognitive Level: Understanding REF: MCS: 785 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 15. What manifestation observed by the nurse is suggestive of parental overprotection? a. Gives inconsistent discipline b. Facilitates the childs responsibility for self-care of illness c. Persuades the child to take on activities of daily living even when not able d. Encourages social and educational activities not appropriate to the childs level of capability ANS: A Parental overprotection is manifested when the parents fear letting the child achieve any new skill, avoid sacllipdli ne, and cater to every desire to prevent frustration. Overprotective parents do not allow the child to assume responsibility for self-care of the illness. The parents prefer to remain in the role of total caregiver. eTnhtes pdaornot encourage the child to participate in social and educational activities. DIF: Cognitive Level: Analyzing REF: MCS: 785 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 16. What finding by the nurse is most characteristic of chronic sorrow? a. Lack of acceptance of childs limitation b. Lack of available support to prevent sorrow c. Periods of intensified sorrow when experiencing anger and guilt d. Periods of intensified sorrow at certain landmarks of the childs development ANS: D Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The sorrow is a response to the recognition of the childs limitations. The family should be assessed in an ongoing manner to provide appropriate support as their needs change. The sorrow is not preventable. The chronic sorrow occurs during the reintegration and acknowledgment stage. DIF: Cognitive Level: Analyzing REF: MCS: 785 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 17. A 5-year-old child will be starting kindergarten next month. She has cerebral palsy, and it has been determined that she nteoebdes in a special education classroom. Her parents are tearful when telling the nurse about this and state that they did not lriezae her di sability was so severe. What is the best interpretation of this situation? a. This is a sign the parents are in denial. b. This is a normal anticipated time of parental stress. c. The parents need to learn more about cerebral palsy. d. The parents expectations are too high. ANS: B Parenting tahcahiclhdrwonii c illness can tbreesssful. A t certain anticipated times, parental stress increases. One of these identifiedmties i s when the child begins school. Nurses can help parents recognize and plan interventions to work through these stressful periods. The parents are not in denial; rather, they are responding to the childs placement in school. The parents are not exhibiting signs of a remembericg def with this child. it; tihr ifsirisst tihneteractio n with the school system DIF: Cognitive Level: Analyzing REF: MCS: 778 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 18. The nurse notes that the parents of a critically ill child spend a large amount of time talking with the parents of another child who is also seriously ill. They talk with these parents more than with the nurses. How should the nurse interpret this situation? a. Parent-to-parent support is valuable. b. Dependence on other parents in crisis is unhealthy. c. This is occurring because the nurses are unresponsive to the parents. d. This has the potential to increase friction between the parents and nursing staff. ANS: A Veteran parents share experiences that cannot be supplied by other support systems. They have known the stress related to diagnosis, have weathered the many transition times, and have a practical remembering of resources. The parents can be mutually supportive during times of crisis. Nursing staff cannot provide the type of support that is realized from other parents who are experiencing similar situations. Friction should nxoistt ebetween the family of the child who is critically ill. sniunrg staff and the DIF: Cognitive Level: Applying REF: MCS: 787 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 19. The nurse is talking to the parent of a child with special needs. The parent has expressed worry about how to support the siblings at home. What suggestion is appropriate for the nurse to give to the parent? a. You should help the siblings see the similarities and differences between themselves and your child with special needs. b. You should explain that your child with special needs should be included in all activities that the siblings participate in even if they are reluctant. c. You should give the siblings many caregiving tasks for your child with special needs so the siblings feel involved. d. You should intervene when there are differences between your child with special needs and the siblings. ANS: A Appropriate information to give to a parent who wants to support the siblings of a child with special needs includes helping the siblings see the differences and similarities between themselves and the child with special needs to promote an understanding environment. The parent should be encouraged to allow the siblings to participate in activities that do not always include the child with special needs, to limit caregiving responsibilities, and to allow the children to settle their own differences rather than step in all the time. DIF: Cognitive Level: Applying REF: MCS: 779 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 20. What is the single most prevalent cause of disability in children and responsible for the recent increase in childhood disability? a. Cancer b. Asthma c. Seizures d. Heart disease ANS: B Asthma is the single most prevalent cause of disability in children and has been largely responsible for much of the recent increase in childhood disability. DIF: Cognitive Level: Understanding REF: MCS: 762 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 21. The parents of a child on a ventilator tell the nurse that their insurance company wants the child to be discharged. They explain that they do not want the child home under any circumstances. What principle should the nurse consider when working with this family? a. Desire to have the child home is essential toeecftfive home care. b. Parents should not be expected to care for a technology-dependent child. c. Having a technology-dependent child at home is better for both the child and the family. d. Parents are not part of the decision-making process because of the costs of hospitalization. ANS: A Home care requires the family tohme anage t childs illness, including providing daily hands-on care, monitoring the childs medical condition, and educating others to care for the child. The childs home environment with the childs family is perceived as the best place for the child to be cared for. If the family does not want to or is not able to assume these responsibilities, other arrangements need to be investigated. The family is anieaslspeant rt of the decision-making process. Without family involvement and support, the technology-dependent child will not be well cared for at home. DIF: Cognitive Level: Understanding REF: MCS: 763 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 22. A child with a serious chronic illness will soon go home. Tcahsee manager requests that the family provide total care for the child for a couple of days while the child is still hospitalized. How should the request be viewed? a. Improper because of legal issues b. Supportive because families are usually eager to get involved c. Unacceptable because the family will have to assume the care soon enough d. Important because it can be beneficial to the transition from hospital to home ANS: D This type of groundwork is essential for the family. Adequate family training and preparation will assist in the childs transition home. The nursing staff in the hospital is responsible for the childs care. The family will provide the care with assistance as needed. Although parents are eager to be involved, the purpose of this intervention is the development of family competency and dcoencfie that they ar e capable. Arrangements for irteespcar e are important for the family both during hospitalizations and while the child is at home. DIF: Cognitive Level: Understanding REF: MCS: 778 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 23. For case management to be most effective, who should be recognized as the most appropriate case manager? a. Nurse b. Panel of experts c. Multidisciplinary team d. Insurance company ANS: A Nursing acnasaegemrs are ideally s uited to provide the care coordination necessary. Care coordination is most effective if a single person works with the family to accomplish the many tasks and responsibilities that are necessary. The family retains the role as primary decision maker. Most likely the insurance company will have a case manager focusing on the financial aspects of care. This does not include coordination of care to assist the family. DIF: Cognitive Level: Understanding REF: MCS: 782 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 24. An adolescent with long-term, complex health care needs will soon be discharged from the hospital. The nurse case manager has been assigned to the teen and family. The adolescents care involves physical therapy, occupational therapy, and speech therapy in addition to medical and nursing care. Who should be the decision maker in the adolescents care? a. Adolescent b. Nurse case manager c. Adolescent and family d. Multidisciplinary health care team ANS: C The extent to which children are involved in their own care and decision making depends on many factors, including the childs developmental age, level of interest, physical ability, and parental support. If the adolescent is developmentally age appropriate, then decision making should be the responsibility of child and family. Family needs to be involved because they will be caring for tahdeolescent in the home. Health care providers have necessary input into the care of the child, but ultimate decision making rests with the adolescent and family. DIF: Cognitive Level: Applying REF: MCS: 767 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 25. The nurse has beengansesdi as a home health nur se for a child who is technology dependent. The nurse recognizes that the familys background differs widely from the nurses own. The nurse believes some of their lifestyle choices are less than aidl.eW hat nursing intervention is most appropriate to institute? a. Change the family. b. Respect the differences. c. Assess why the family is different. d. Determine whether the family is dysfunctional. ANS: B Respect for varied family structures and for racial, ethnic, cultural, and socioeconomic diversity among families is essential in home care. The nurse must assess and respect the familys background and lifestyle choices. It is not appropriate to attempt to change the family. The nurse is a guest in the home and care of the child. The family and the values held by the cultural group prevail. The nurse may assess why the family is different to help the nurse and other health professionals understand the differences. It is not appropriate to determine whether the family is dysfunctional. DIF: Cognitive Level: Applying REF: MCS: 774 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 26. A childs parents ask the nurse many questions about their childs illness and its management. The nurse does not know enough to answer all the questions. What nursing action is most appropriate at this time? a. Tell them, I dont know, but I will find out. b. Suggest that they ask the physician these questions. c. Explain that the nurse cannot be expected to know everything. d. Answer questions vaguely so they do not lose confidence in the nurse. ANS: A Questions from parents should be answered in a straightforward manner. Stating I dont know or Ill find out is better than pretending to know or giving excuses. Suggesting that they ask the physician these questions is not isvueppoofrt the family. The nurses role is to assist the parents in obtaining accurate information about their childs illness and its management. Although the nurse cannot be expected to know everything, it is an unprofessional attitude to state this. Nurses must provide accurate information to the extent possible. Vague answers are not helpful to the family. DIF: Cognitive Level: Applying REF: MCS: 775 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment 27. The nurse outlines short- and long-term goals for a 10-year-old child with many complex health problems. Who should agree on these goals? a. Family and nurse b. Child, family, and nurse c. All professionals involved d. Child, family, and all professionals involved ANS: D In the home, the family is a partner in each step of the nursing process. The family priorities should guide the planning process. Both short- and long-term goals should be outlined and agreed on by the child, family, and professionals involved. Elimination of any one of these groups can potentially create a care plan that does not meet the needs of the child and family. DIF: Cognitive Level: Analyzing REF: MCS: 777 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 28. When communicating with other professionals about a child with a chronic illness, what is important for nurses to do? a. Ask others what they want to know. b. Share everything known about the family. c. Restrict communication to clinically relevant information. d. Recognize that confidentiality is not possible in home care. ANS: C The nurse needs to share, through both oral and written communication, clinically relevant information with other involved health professionals. Asking others what they want to know and sharing everything known about the family are inappropriate measures. Patients have a right to confidentiality. Confidentiality permits cthloesduirse of information torothe professionals on a need-to-know basis. DIF: Cognitive Level: Applying REF: MCS: 761 TOP: Integrated Process: Communication and Documentation health MSC: Client Needs: Safe and Effective Care Environment: Management of Care 29. The nurse has been visiting an adolescent with recently acquired tetraplegia. The teens mother tells the nurse, Im sick of providing all the care while my husband does whatever he wants to, whenever he wants to do it. What reaction should be the nurses initial response? a. Refer the mother for counseling. b. Listen and reflect the mothers feelings. c. Ask the father in private why he does not help. d. Suggest ways the mother can get her husband to help. ANS: B It is appropriate for the nurse to reflect with the mother about her feelings, exploring solutions such as an additional home health aide to help care for the child and provide respite for the mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping enough. This judgment is beyond the role of the nurse and can undermine the family relationship. Counseling, if indicated, would be necessary for both parents. A support group for caregivers may be indicated. The nurse should not ask the father in private why he does not help or suggest way the mother can get her husband to help. These interventions are based on the mothers perceptions; the father may have a full-time job and other commitments. The parents may need an unbiased third person to help them through the negotiation of their new parenting responsibilities. DIF: Cognitive Level: Applying REF: MCS: 763 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Itengrity 30. The nurse is planning care for a 3-year-old boy who has Down syndrome and is on continuous oxygen. He recently began walking around furniture. He is spoon fed by his parents and eats some finger foods. What goal is the most appropriate to promote normal development? a. Encourage mobility. b. Encourage assistance in self-care. c. Promote oral-motor development. d. Provide opportunities for socialization. ANS: A A major principle for developmental support in children with complex medical issues is that it should be flexible and tailored to the individual childs abilities, interests, and needs. This child is exhibiting readiness for ambulation. It is an appropriate time to provide activities that encourage mobility, for example, longer oxygen tubing. Parents should provide decreasing amounts of assistance with self-care as he is able to develop these skills. The boy is receiving oral foods and is eating finger foods. He has acquired this skill. Mobility is a new developmental task. Opportunities for socialization should be ongoing. DIF: Cognitive Level: Applying REF: MCS: 763 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 31. What behavior seen in children should be addressed by the nurse who is providing care to a child with a chronic illness? a. An infant who is uncooperative b. A toddler who expresses loneliness c. A preschooler who refuses to participate in self-care d. An adolescent who is showing independence ANS: C Preschoolers thrive on being independent and are in the phase of gaining autonomy, so they want to perform as many self-care tasks as possible. If a preschooler is refusing to participate in self- care activities, then the home health nurse should address this. Infants are uncooperative by nature, and toddlers do not understand the concept of loneliness, so these are not observations that would need to be addressed. Adolescents are always striving for independence, so this is a normal observation; if the adolescent were becoming more dependent on family, it might require intervention. DIF: Cognitive Level: Applying REF: MCS: 768 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 32. The nurse asks the mother of a child with a chronic illness many questions as part of the assessment. The mother answers several questions, thensstaonpd says, I dont know washky you me all this. Who gets to know this information? The nurse should respond in what manner? a. Determine why the mother is so suspicious. b. Determine what the mother does not want to tell. c. Explain who will have access to the information. d. Explain that everything is confidential and that no one else will know what is said. ANS: C Communication with the family should not be invasive. The nurse needs to explain the importance of collecting the information, its applicability to the childs care, and who will have access to the information. The mother is not being suspicious and is not necessarily withholding important information. She has a right to understand how the information she provides will be used. The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals. DIF: Cognitive Level: Applying REF: MCS: 773 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment 33. One of the supervisors for a home health agencyhaesks t nurse to give a family of a child with a chronic illness a survey evaluating ethse nurs nurse recognize this request? and other service providers. How should the a. Appropriate to improve quality of care b. Improper because it is an invasion of privacy c. Inappropriate unless nurses and other providers agree to participate d. Not acceptable because the family lacks remembering necessary to evaluate professionals ANS: A Quality assessment and improvement eacetivities ar ssential for virtually all organizations. Family involvement inueavtainlg a home care plan can occur on several levels. The nurse can ask the family open-ended questions at regular intervals to assess their opinion of the effectiveness of care. Families should also be given an opportunity to evaluate the individual home care nurses,ethhome care agency, and other service providers periodically. Evaluation of the provision of care to the patient and family requires evaluation of the care provider, that is, the nurse. Quality-monitoring taicvities a re required by virtually rall health ca e agencies. During the evaluation process, the family is asked to provide their perceptions of care. DIF: Cognitive Level: Applying REF: MCS: 763 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is planning to use an interpreter with a nonEnglish-speaking family. What should the nurse plan with regard to the use of an interpreter? (Select all that apply.) a. Use a family member. b. The nurse should speak slowly. c. Use an interpreter familiar with the familys culture. d. The nurse should speak only a few sentences at a time. e. The nurse should speak to the interpreter during interactions. ANS: B, C, D When parents who do not speak English are informed of their childs chronic illness, interpreters familiar with both their culture and language should be used. The nurse should speak slowly and only use a few sentences at a time. Children, family members, and friends of the family should not be used as translators because their presence may prevent parents from openly discussing the issues. The nurse should speak to the family, not the interpreter. DIF: Cognitive Level: Applying REF: MCS: 765 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 2. The nurse is teaching coping strategies to parents of a child with a chronic illness. What coping strategies should the nurse include? (Select all that apply.) a. Listen to the child. b. Accept the childs illness. c. Establish a support system. d. Learn to care for the childs illness one day at a time. e. Do not share information with the child about the illness. ANS: A, B, C, D Coping strategies for parents caring for a child with a chronic illness include listening to the child, accepting the childs illness, establishing a support system, and learning to care for the childs illness one day at a time. Information should be shared with the child about the illness. DIF: Cognitive Level: Applying REF: MCS: 782 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. What are supportive interventions athnaat c sisst an infan t with a ochnric illnes s to meet developmental milestones? (Select all that apply.) a. Encourage consistent caregivers. b. Encourage periodic respite from demands of care. c. Encourage one family member to be the primary caretaker. d. Encourage parental rooming in during hospitalization. e. Withhold age-appropriate developmental tasks until the child is older. ANS: A, B, D To develop trust, consistent caretakers and parents rooming in should be encouraged. To develop a sense of separateness from penarts, periodic respites from caregiving should be encouraged. All members of the family, not one primary caretaker, should be encouraged to participate in care. Age-appropriate developmental tasks should be encouraged, not withheld until an older age. DIF: Cognitive Level: Analyzing REF: MCS: 766 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. The nurse is assessing coping behaviors of a family with a child with a chronic illness. What indicates approach coping behaviors? (Select all that apply.) a. Plans realistically for the future b. Verbalizes possible loss of the child c. Uses magical thinking and fantasy d. Realistically perceives the childs condition e. Does not share the burden of the disorder with others ANS: A, B, D Approach coping behaviors include planning realistically for the future, verbalizing possible loss of a child, and realistically perceiving the childs behavior. Using magical thinking and fantasy is an avoidance behavior. The family should share the burden of the disorder with others as an approach behavior. DIF: Cognitive Level: Analyzing REF: MCS: 783 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 5. What are supportive interventions athnaat c sisst a toddle r withoanicchri llness to meet developmental milestones? (Select all that apply.) a. Give choices. b. Provide sensory experiences. c. Avoid discipline and limit setting. d. Discourage negative and ritualistic behaviors. e. Encourage independence in as many areas as possible. ANS: A, B, E To encourage autonomy, choices should be given and independence encouraged in as many areas as possible. Sensory experiences should be encouraged to help the toddler to learn through sensorimotor experiences. Age-appropriate discipline and limit setting should be initiated. Negative and ritualistic behaviors are normal and should be allowed. DIF: Cognitive Level: Analyzing REF: MCS: 766 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 6. The nurse is assessing coping behaviors of a family with a child with a chronic illness. What indicates avoidance coping behaviors? (Select all that apply.) a. Refuses to agree to treatment b. Avoids staff, family members, or child c. Is unable to discuss possible loss of the child d. Recognizes own growth through a passage of time e. Makes no change in lifestyle to meet the needs of other family members ANS: A, B, C, E Avoidance coping behaviors include refusing to agree to treatment; avoiding staff, family members, or child; unable to discuss possible loss of the child; and making no change in lifestyle to meet the needs of other family members. Recognizing ones own growth through a passage of time is an approach behavior. DIF: Cognitive Level: Analyzing REF: MCS: 783 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Health Promotion and Maintenance 7. What are supportive interventions athnaat c sisst a p reschooler with a chronic illness to meet developmental milestones? (Select all that apply.) a. Encourage socialization. b. Encourage mastery of self-help skills. c. Provide devices that make tasks easier. d. Clarify that the cause of the childs illness is not his or her fault. e. Discuss planning for the future and how the condition can affect choices. ANS: A, B, C, D To encourage initiative, mastery of self-help skills should be encouraged, and devices should be provided that make tasks easier. To develop peer relationships, socialization should be encouraged. To develop body image, the fact that the cause of the childs illness is not the fault of the child should be emphasized. Discussing planning for the future and how the condition can affect choices is appropriate for an adolescent. DIF: Cognitive Level: Analyzing REF: MCS: 766 TOP: NursoicnegssP:rAssessment :MSC Client Needs: Health Promotion and Maintenance 8. The parent of a child with a chronic illness tells the nurse, I feel so hopeless in this situation. The nurse should take which actions to foster hopefulness for the family? (Select all that apply.) a. Avoid topics that are lighthearted. b. Convey a personal interest in the child. c. Be honest when reporting on the childs condition. d. Do not initiate any playful interaction with the child. e. Demonstrate competence and gentleness when delivering care. ANS: B, C, E To foster hopefulness, the nurse should convey a personal interest in the child, be honest when reporting on a childs condition, and demonstrate competence and gentleness when delivering care. The nurse should introduce conversations on neutral, nondisease-related, or less sensitive topics (discuss the childs favorite sports, tell stories). The nurse should be lighthearted and initiate or respond to teasing or other playful interactions with the child. DIF: Cognitive Level: Applying REF: MCS: 767 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. What are supportive interventions that can assist a school-age child with a chronic illness to meet developmental milestones? (Select all that apply.) a. Encourage socialization. b. Discourage sports activities. c. Encourage school attendance. d. Provide instructions on assertiveness. e. Educate teachers and classmates about the childs condition. ANS: A, C, E To develop a sense of accomplishment, school attendance should be encouraged, and teachers and classmates should be educated about the childs condition. To form peer relationships, socialization should be encouraged. Sports activities should be encouraged (e.g., Special Olympics), not discouraged. Providing instructions on assertiveness is appropriate for adolescence. Chapter 20.The Child with Cognitive, Sensory, or Communication Impairment MULTIPLE CHOICE 1. The American Association on Intellectual and Developmental Disabilities (AAIDD), formerly the American Association on Cognitive Impairment, classifies cognitive impairment based on what parameter? a. Age of onset b. Subaverage intelligence c. Adaptive skill domains d. Causative factors for cognitive impairment ANS: C The AAIDD has categorized cognitive impairment into adaptive skill domains. The child must demonstrate functional impairment in at least two of the following adaptive skill domains: communication, self-care, home living, social skills, use of community resources, self-direction, health and safety, functional academics, leisure, and work. Age of onset before 18 years is part of the former criteria. Low intelligence quotient (IQ) alone is not the lseo c riterion for cognitive impairment. Etiology is not part of the classification. DIF: Cognitive Level: Understanding REF: MCS: 824 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 2. Secondary prevention for cognitive impairment includes what activity? a. Genetic counseling b. Avoidance of prenatal rubella infection c. Preschool education and counseling services d. Newborn screening for treatable inborn errors of metabolism ANS: D Secondary prevention involves activities that are designed to identify the condition early and initiate treatment to avert cerebral damage. Inborn errors of metabolism such as hypothyroidism, phenylketonuria, and galactosemia can cause cognitive impairment. Genetic counseling and avoidance of prenatal rubella infections are examples of primary prevention strategies to preclude the occurrence of disorders that can cause cognitive impairment. Preschool education and counseling services are examples of tertiary prevention. These are designed to include early identification of conditions and provision of appropriate therapies and rehabilitation services. DIF: Cognitive Level: Understanding REF: MCS: 826 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 3. What is a primary goal in caring for a child with cognitive impairment? a. Developing vocational skills b. Promoting optimum development c. Finding appropriate out-of-home care d. Helping child and family adjust to future care ANS: B The goal for children with cognitive impairment is the promotion of optimum social, physical, cognitive, and adaptive development as individuals within a family and community. Vocational skills are only one part of that goal. The focus must also be on the family and other aspects of development. Out-of-home care is considered part of the childs development. Optimum development includes adjustment for both the family and child. DIF: Cognitive Level: Understanding REF: MCS: 828 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 4. One of the techniques that has been especially useful for learners having cognitive impairment is called fading. What description best explains this technique? a. Positive reinforcement when tasks or behaviors are mastered b. Repeated verbal explanations until tasks are faded into the childs development c. Negative reinforcement for specific tasks or behaviors that need to be faded out d. Gradually reduces the assistance given to the child so the child becomes more independent ANS: D Fading is physically taking the child through each sequence of the desired activity and gradually fading out the physical assistance so the child becomes more independent. Positive reinforcement when tasks or vbieohras are mastered is part of behavior fmicoadtion. An essential component is ignoring undesirable behaviors.bValerexpl anations are not as effective as demonstration and physical guidance. Consistent negative reinforcement is helpful, but positive reinforcement that focuses on skill attainment should be incorporated. DIF: Cognitive Level: Analyzing REF: MCS: 827 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 5. The parents of a child with cognitive impairment ask the nurse for guidance with discipline. What should the nurses recommendation be based on? a. Discipline is ineffective with cognitively impaired children. b. Cognitively impaired children do not require discipline. c. Behavior modification is an excellent form of discipline. d. Physical punishment is the most appropriate form of discipline. ANS: C Discipline must begin early. Limit-setting measures must be clear, simple, consistent, and appropriate for the childs mental age.vBioerha modification, especially reinforcement of desired behavior and use of time-out procedures, is an appropriate form of behavior control. Aversive strategies should be avoided in disciplining the child. DIF: Cognitive Level: Applying REF: MCS: 827 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. What intervention is most appropriate to facilitate social development of a child with a cognitive impairment? a. Provide age-appropriate toys and play activities. b. Avoid exposure to strangers who may not understand cognitive development. c. Provide peer experiences, such as infant stimulation and preschool programs. d. Emphasize mastery of physical skills because they are delayed more often than verbal skills. ANS: C The acquisition of social skills is a complex task. Initially, an infant stimulation program should be used. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is ipmortant, bu t peer interactions facilitate social development. Parents should expose the child to individuals who do not know the child. This enables the child to practice social skills. Verbal skills are delayed more often than physical skills. DIF: Cognitive Level: Applying REF: MCS: 835 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 7. The nurse is discussing sexuality with the parents of an adolescent girl who has a moderate cognitive impairment. What factor should the nurse consider when dealing with this issue? a. Sterilization is recommended for any adolescent with cognitive impairment. b. Sexual drive and interest are very limited in individuals with cognitive impairment. c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused. ANS: C Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be defined for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychologic effects oandothlescent. I t may be prohibited in some states. The adolescent nteoehdas ve practical sl eixua nformation regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances. DIF: Cognitive Level: Applying REF: MCS: 829 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. The mother of a young child with cognitive impairment asks for suggestions about how to teach her child to use a spoon for eating. The nurse should make which recommendation? a. Do a task analysis first. b. Do not expect this task to be learned. c. Continue to spoon feed the child until the child tries to do it alone. d. Offer only finger foods so spoon feeding is unnecessary. ANS: A Successful teaching ibnesgwith a task anaysis.l T he endpoint (self-feeding, toilet training, and so on) is broken down into the component steps. The child is then guided to master the individual steps in sequence. Depending on the childs functional level, using a spoon for eating should be an achievable goal. The child requires demonstration and then guided training for each component of the self-feeding. Feeding finger foods so spoon feeding is unnecessary eliminates some of the intermediate steps that are necessary to using a fork and spoon. For socialization purposes, it is desirable that a child use feeding implements. DIF: Cognitive Level: Understanding REF: MCS: 827 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. A newborn assessment shows a separated sagittal suture, oblique palpebral fissures, a depressed nasal bridge, a protruding tongue, and transverse palmar creases. These findings are most suggestive of which condition? a. Microcephaly b. Cerebral palsy c. Down syndrome d. Fragile X syndrome ANS: C These are characteristics associatedtwh iD own syndrome. An infant twhimicrocephaly ha s a small head. Cerebral palsy is a diagnosis not usually made at birth; no characteristic physical signs are present. Tinhfaent twhif ragile X syndrome has increased head circumference; long, wide, or protruding ears; a long, narrow face with a prominent jaw; hypotonia; and a high-arched palate. DIF: Cognitive Level: Understanding REF: MCS: 834 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold, that hes like a rag doll. He doesnt cuddle up to me like my other babies did. What is the nurses best interpretation of this lack of clinging or molding? a. Sign of detachment and rejection b. Indicative of maternal deprivation c. A physical characteristic of Down syndrome d. Suggestive of autism associated with Down syndrome ANS: C Infants with Down syndrome have hypotonicity of muscles and hyperextensibility of joints, which complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll. Holding the infant is difficult and cumbersome, and parents may tfetel tha hey are inadequate. A lack of clinging or molding is characteristic of Down syndrome, not detachment. There is no evidence of maternal deprivation. Autism is not associated with Down syndrome, and it would not be evident at 2 weeks of age. DIF: Cognitive Level: Analyzing REF: MCS: 836 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 11. Many of the clinical features of Down syndrome present challenges to caregivers. Based on these features, what intervention should be included in the childs care? a. Delay feeding solid foods until the tongue thrust has stopped. b. Modify the diet as necessary to minimize the diarrhea that often occurs. c. Provide calories appropriate to the childs mental age. d. Use a cool-mist vaporizer to keep the mucous membranes moist and secretions liquefied. ANS: D The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep the mucous membranes moist and liquefy secretions. Respiratory tract infections combined with cardiac anomalies are the primaryecaouf s death in the first years. The child has a protruding tongue, which makes feeding difficult. The parents must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is predisposed to constipation. Calories should be appropriate to the childs weight and growth needs, not mental age. DIF: Cognitive Level: Applying REF: MCS: 837 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 12. What description applies to fragile X syndrome? a. Chromosomal defect affecting only females b. Second most common genetic cause of cognitive impairment c. Most common cause of uninherited cognitive impairment d. Chromosomal defect that follows the pattern of X-linked recessive disorders ANS: B Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily affects males and follows the pattern of X-linked dominant inheritance with reduced penetrance. DIF: Cognitive Level: Understanding REF: MCS: 837 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. The nurse should suspect a hearing impairment in an infant who fails to demonstrate which behavior? a. Babbling by age 12 months b. Eye contact when being spoken to c. Startle or blink reflex to sound d. Gesturing to indicate wants after age 15 months ANS: A The absence of babbling or inflections in voice by at least age 7 months is an indication of hearing difficulties. Lack of eye contact is not dinicative of a hearing loss. An infant with a hearing impairment might react to a loud noise but not respond to the spoken word. The child with hearing impairment uses gestures rather than vocalizations to express desires at this age. DIF: Cognitive Level: Understanding REF: MCS: 854 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 14. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What intervention is the most appropriate nursing action? a. Ignore the sound. b. Suggest he reinsert the hearing aid. c. Ask him to reverse the hearing aids in his ears. d. Suggest he raise the volume of the hearing aid. ANS: B The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure no hair is caught between the ear mold and the ear canal. Ignoring the sound or suggesting he raise the volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear. DIF: Cognitive Level: Applying REF: MCS: 842 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 15. What technique facilitates lip reading by a hearing-impairedlcdh?i a. Speak at an even rate. b. Avoid using facial expressions. c. Exaggerate pronunciation of words. d. Repeat in exactly the same way if child does not understand. ANS: A Help the child learn and understand how to read lips by speaking at an even rate. Avoiding using facial expressions, exaggerating pronunciation of words, and repeating in exactly the same way if the child does not understand interfere with the childs understanding of the spoken word. DIF: Cognitive Level: Applying REF: MCS: 843 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 16. What condition is defined as reduced visual acuity in one eye despite appropriate optical correction? a. Myopia b. Hyperopia c. Amblyopia d. Astigmatism ANS: C Amblyopia, or lazy eye, iesdruced visual acuity in one eye. Amblyopia is usually caused by one eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be avoided with the treatment of the primary visual defect such as strabismus. Myopia, or nearsightedness,erref s to the ability to see objects clearly at close range but not a distance. Hyperopia, or farsightedness, is the ability to see objects at a distance but not at ocls e range. Astigmatism is unequal curvatures in refractive apparatus. DIF: Cognitive Level: Understanding REF: MCS: 844 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 17. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes what intervention? a. Place a cool compress on eye during transport to the emergency department. b. Irrigate the eye copiously with a sterile saline solution. c. Remove the object with a lightly moistened gauze pad. d. Apply a Fox shield to the affected eye and any type of patch to the other eye. ANS: D The nurses role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye and a regular eye patch to the other eye to prevent bilateral movement. Placing cool compress on the eye during transport to emergency department, irrigating eye copiously with a sterile saline solution, or removing object with a lightly moistened gauze pad may cause more damage to the eye. DIF: Cognitive Level: Applying REF: MCS: 847 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. A father calls the emergencyadretmp ent nurse saying that his daughters eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. The nurse also should recommend which action before the child is trapnosrted? a. Keep the eyes closed. b. Apply cold compresses. c. Irrigate the eyes copiously with tap water for 20 minutes. d. Prepare a normal saline solution (salt and water) and irrigate the eyes for 20 minutes. ANS: C The first action is to flush the seywe ith aclnet ap water. This will rinse the detergent from the eyes. Keeping the eyes closed and applying cold compresses may allow tdhe tergent to do further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the detergent to cause continued injury to the eyes. DIF: Cognitive Level: Applying REF: MCS: 847 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19. A 5-year-old child has bilateral eye patches in place after surgery yesterday morning. Today he can be out of bed. What nursing intervention is most important at this time? a. Speak to him when entering the room. b. Allow him to assist in feeding himself. c. Orient him to his immediate surroundings. d. Reassure him and allow his parents to stay with him. ANS: C Safety is the priority concern. Because he can now be out of bed, it is imperative that he knows about his physical surroundings. Speaking to lthe chi d is a component of nursing care that is expected with all clients unless contraindicated. Unless additional impairments are present, his meal tray should be set up, and he should be able to feed himself. Reassuring him and allowing his parents to stay with him are essential parts of nursing care for all children. DIF: Cognitive Level: Applying REF: MCS: 849 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 20. Autism is a complex developmental disorder. The gdniaostic c riteria for autism include delayed or abnormal functioning in which area with onset before age 3 years? a. Parallel play b. Gross motor development c. Ability to maintain eye contact d. Growth below the fifth percentile ANS: C One hallmark of autism spectrum disorders is the childs inability to maintain eye tcaocnt with another person. Parallel play is play typical of toddlers and is usually not affected. Social, not gross motor, development is affected by autism. Physical growth and development are not usually affected. DIF: Cognitive Level: Understanding REF: MCS: 845 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 21. What intervention should be included in the nursing care of a child with autism spectrum disorder (ASD)? a. Assign multiple staff to care for the child. b. Communicate with the child at his or her developmental level. c. Provide a wide variety of foods for the child to try. d. Place the child in a semiprivate room with a roommate of a similar age. ANS: B Children with ASD require individualized care. The nurse needs to communicate with the child at the childs developmental nlesvisetle. nCtocaregivers a re essential for children with ASD. The same staff members should care for the child as much as possible. Children with ASD do not adapt to changing situations. The same foods should be provided to allow the child to adjust. A private room is desirable for children with ASD. Stimulation is minimized. DIF: Cognitive Level: Applying REF: MCS: 857 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 22. What suggestion by the nurse for parents regarding stuttering in children is most helpful? a. Offer rewards for proper speech. b. Encourage the child to take it easy and go slow when stuttering. c. Help the child by supplying words when he or she is experiencing a block. d. Give the child plenty of time and the impression that you are not in a hurry. ANS: D Hesitancy and dysfluency should be considered a normal part of speech development. An important approach is to allow the child plenty of time to speak. Promising rewards for proper speech places additional pressure on the child. Encouraging the child to take it easy and go slow when stuttering draws attention to the dysfluency. The child needs to complete a sentence and thought without being interrupted. DIF: Cognitive Level: Understanding REF: MCS: 858 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 23. What observation in a child should indicate the need for a referral to a specialist regarding a communication impairment? a. At 2 years of age, the child fails to respond consistently to sounds. b. At 3 years of age, the child fails to use sentences of more than five words. c. At 4 years of age, the child has impaired sentence structure. d. At 5 years of age, the child has poor voice quality. ANS: A If a 2-year-old child fails to respond consistently to sounds, it is an indication for referral to a specialist regarding communication impairment. At age 3 years, the iclhd failing toeus entences of three words would be an indication for referral; impaired sentence structure would be seen in a 5-year-old child and poor voice quality in an older child who has a communication impairment. DIF: Cognitive Level: Applying REF: MCS: 859 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 24. The nurse is performing a physical assessment on a 3-year-old child. The parents state that the child excessively rubs the eyes and often tilts the head to one side. What visual impairment should the nurse suspect? a. Strabismus b. Astigmatism c. Hyperopia, or farsightedness d. Myopia, or nearsightedness ANS: D Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading, headaches, and rdaizbzisinmeuss,. aSstt igmatism, and hyperopia have other icnlical manifestations. DIF: Cognitive Level: Applying REF: MCS: 845 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 25. The community nurse is planning prevention measures designed to avoid conditions that can cause cognitive impairment. Taking folic acid supplements during pregnancy to prevent neural tube defects is which type of prevention strategy? a. Primary b. Secondary c. Tertiary d. Rehabilitative ANS: A Primary prevention strategies are those designed to avoid conditions that cause cognitive impairment. Use of folic acid supplements during pregnancy to prevent neural tube defects is a primary prevention strategy. Secondary prevention activities are those designed to identify the condition leyarand initiate treatment to avert cerebral damage. Tertiary prevention strategies are those concerned with treatment to minimize long-term consequences. Rehabilitation services is an example of tertiary prevention. DIF: Cognitive Level: Analyzing REF: MCS: 825 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 26. The nurse is teaching a preschool child with a cognitive impairment how to throw a ball overhand. Wachiantgtestrategy should the nurse use for this child? a. Demonstrate how to throw a ball overhand. b. Explain the reason for throwing a ball overhand. c. Show pictures of children throwing balls overhand. d. Explain to the child how to throw the ball overhand. ANS: A Children with cognitive impairment have a deficit in discrimination, which means that concrete ideas are much easier toelcetairvneleyffthan abstract ideas. T herefore, demonstration is preferable to verbal explanation, and the nurse should direct learning toward mastering a skill rather than understanding the scientific principles underlying a procedure. Demonstrating how to throw the ball is the best teaching strategy. DIF: Cognitive Level: Applying REF: MCS: 827 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 27. The camp nurse is choosing a toy for a child with cognitive impairment to play with during swimming time. What toy should the nurse choose to encourage improvement of developmental skills? a. Dive rings b. An inner tube c. Floating ducks d. A large beach ball ANS: D Toys are selected ftohreir recreational and educational value. For example, a large inflatable beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills such as balance, rocking, kicking, and throwing. Dive rings, an inner tube, and floating ducks are not interactive toys. DIF: Cognitive Level: Applying REF: MCS: 829 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 28. The nurse is teaching feeding strategies to a parent of a 12-month-old infant with Down syndrome. What statement made by the parent indicates a need for further teaching? a. If the food is thrust out, I will reefed it. b. I will use a small, long, straight-handled spoon. c. I will place the food on the top of the tongue. d. I know the tongue thrust doesnt indicate a refusal of the food. ANS: C Parents of a child with Down syndrome need to know that the tongue thrust does not indicate refusal to feed but is a physiologic response. Parents are advised to use a small but long, straight- handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed. If the parent indicates placing the food on the tongue, further teaching is needed. DIF: Cognitive Level: Applying REF: MCS: 837 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 29. The nurse is counseling a pregnant 35-year-old woman about estimated risk of Down syndrome. What is the estimated risk for a woman who is 35 years of age? a. One in 1200 b. One in 900 c. One in 350 d. One in 100 ANS: C The estimated risk of Down syndrome for a 35-year-old woman is one in 350. One in 1200 is the risk for a 25-year-old woman, one in 900 is the risk for a 30-yearold woman, and one in 100 is the risk for a 40-year-old woman. DIF: Cognitive Level: Applying REF: MCS: 833 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 30. The nurse is teaching epnarts of a child with cataracts about tuhpecoming treatment. The nurse should give the parents what information about the treatment of cataracts? a. The treatment may require more than one surgery. b. It is corrected with biconcave lenses that focus rays on the retina. c. Cataracts require surgery to remove the cloudy lens and replace it. d. Treatment is with a corrective lenses; no surgery is necessary. ANS: C Treatment for cataracts requires surgery to remove the cloudy lens and replace it (with an intraocular lens implant, removable contact lens, or prescription glasses). Treatment for glaucoma may require more than one surgery. Anisometropia is treated with corrective lenses. Myopia is corrected with biconcave lenses that focus rays on the retina. DIF: Cognitive Level: Applying REF: MCS: 846 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 3In1t.eWgrihtayt action should the school nurse take for a child who has a hematoma (black eye) with no hemorrhage into the anterior chamber? a. Apply a warm moist pack. b. Have the child keep the eyes open. c. Apply ice for the first 24 hours. d. Refer to an ophthalmologist immediately. ANS: C The care for a hematoma eye injury with no hemorrhage into the anterior chamber is to apply ice for the first 24 hours. A warm moist pack should not be applied, and the child should keep the eyes closed. Referral to an ophthalmologist is recommended if hyphema (hemorrhage into the anterior chamber) is present. DIF: Cognitive Level: Applying REF: MCS: 847 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is preparing an education program on hearing impairment for a group of new staff nurses. What concepts should be included? (Select all that apply.) a. A child with a slight hearing loss is usually unaware of a hearing difficulty. b. A clinical manifestation of a hearing impairment in children is avoidance of social interaction. c. A child with a severe hearing loss may hear a loud voice if nearby. d. Children with sensorineural hearing loss can benefit from the use of a hearing aid. e. A clinical manifestation of hearing impairment in an infant is lack of the startle reflex. f. Identification of a hearing loss after the first year is essential to facilitate language development in children. ANS: A, B, C, E When discussing hearing impairment in children, the nurse should include information about differences in hearing losses, such as with a slight hearing loss, the child is usually unaware of a hearing difficulty, and with a severe loss, the child may hear a loud noise if it is nearby. An infant with a hearing loss may lack the startle response, and a hearing impaired child may avoid social interaction. Children with a sensorineural hearing loss would not benefit from a hearing aid. Identification of a hearing loss is imperative in the first 3 to 6 months to facilitate language and educational development for children. DIF: Cognitive Level: Analyzing REF: MCS: 842 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 2. The nurse understands that which gestational disorders can cause a cognitive impairment in the newborn? (Select all that apply.) a. Prematurity b. Postmaturity c. Low birth weight d. Physiological jaundice e. Large for gestational age ANS: A, B, C Prematurity, postmaturity, and low birth weight can be causes of cognitive impairment in newborns. Physiological jaundice and large for gestational age are not associated causes of cognitive impairment in newborns. DIF: Cognitive Level: Understanding REF: MCS: 825 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. The clinic nurse is assessing antinarfant. Wha e early signs of cognitive impairment tnhuerse should discuss with the health care provider? (Select all that apply.) a. Head lag at 11 months of age b. No pincer grasp at 4 months of age c. Colicky incidents at 3 months of age d. Unable to speak two to three words at 24 months of age e. Unresponsiveness to the environment at 12 months of age ANS: A, D, E Early signs of cognitive impairment include gross motor delay (head lag should be established by 6 months, and head lag still present at 11 months is a delay), language delay (normal language development is speaking two to three words by age 12 months; if unable to speak two to three words at 24 months, that is a delay), and unresponsiveness to the environment at 12 months. No pincer grasp at 4 months of age is normal (palmar grasp is the expected finding), and colicky incidents at 3 months of age is a normal finding. DIF: Cognitive Level: Analyzing REF: MCS: 826 TOP: NursoicnegssP:rAssessment MS C: Client Needs: Health Promotion and Maintenance 4. The nurse is teaching parents of a child with a cognitive impairment signs that indicate the child is developmentally ready for dressing training. What signs should the nurse include that indicate the child is developmentally ready for dressing training? (Select all that apply.) a. Can follow verbal commands b. Can sit quietly for 1 to 2 minutes c. Can master every task of dressing d. Can follow physical gestures or cues e. Can relate clothing to the appropriate body part ANS: A, D, E Children are considered developmentally ready for dressing training if they can sit quietly for 3 to 5 minutes (not 1 to 2) while working on a task; can follow physical gestures or cues; can follow verbal commands; and can relate clothing to the appropriate body part, such as socks to feet. As with other self-help skills, the child may not be able to master every task but should be evaluated for evidence of willingness to participate at his or her level of readiness. DIF: Cognitive Level: Applying REF: MCS: 832 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is assessing tahcDhild wi own syndrome. The nurse recognizes that which are possible comorbidities that can occur with Down syndrome? (Select all that apply.) a. Diabetes mellitus b. Hodgkins disease c. Congenital heart defects d. Respiratory tract infections e. Acute megakaryoblastic leukemia ANS: C, D, E Children with Down syndrome often have multiple comorbidities, contributing to numerous other conditions. Respiratory tract infections are prevalent; when combined with cardiac anomalies, they are the chief cause of death, particularly during the first year. The incidence of leukemia is several times more frequent than expected in the general population, and in about half of the cases, the type is acute megakaryoblastic leukemia. DIF: Cognitive Level: Analyzing REF: MCS: 835 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. A child has a slight (2640 dB) degree of hearing loss. The nurse recognizes this amount of hearing loss can have what effect? (Select all that apply.) a. No speech defects b. Difficulty hearing faint speech c. Usually is unaware of the hearing difficulty d. Can distinguish vowels but not consonants e. Unable to understand conversational speech ANS: A, B, C A child with a slight degree of hearing loss has no speech defects, may have difficulty hearing faint speech, and is usually unaware of the hearing difficulty. The ability to distinguish vowels but not consonants is an effect of severe hearing loss and being unable to understand conversational speech is an effect of moderately severe hearing loss. Chapter 21.Family-Centered Care of the Child During Illness and Hospitalization MULTIPLE CHOICE 1. What behavior should most likely be manifested in an infant experiencing the protest phase of separation anxiety? a. Inactivity b. Depression and sadness c. Inconsolable and crying d. Regression to earlier behavior ANS: C For older infants, being inconsolable and crying eisnsdeuring the protest phase of separation anxiety. Inactivity is observed during the stage of despair. The child is much less active and withdraws from others. Depression, sadness, and regression to earlier behaviors are observed during the phase of despair. DIF: Cognitive Level: Understanding REF: MCS: 864 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 2. Because of their striving for independence and productivity, which age group of children is particularly vulnerable to events that may lessen their feeling of control and power? a. Infants b. Toddlers c. Preschoolers d. School-age children ANS: D When a child is hospitalized, the altered family role, physical disability, loss of peer acceptance, lack of productivity, and inability to cope with stress usurp individual power and identity. This is especially detrimental toasgcehochoill-dren, who are striving for independence and productivity and are now experiencing events that decrease their control and power. Infants, toddlers, and preschoolers, although affected by loss of power, are not as significantly affected as school-age children. DIF: Cognitive Level: Analyzing REF: MCS: 866 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 3. Cognitive development influences response to pain. What age group is most concerned with the fear of losing control during a painful experience? a. Toddlers b. Preschoolers c. School-age children d. Adolescents ANS: D Adolescents view illness as physiologic (an organ malfunction) and psychophysiologic (psychologic factors that affect health). Adolescents usually approach pain with self-control. They are concerned with remaining composed and feel embarrassed and ashamed of losing control. Toddlers and preschoolers react to pain primarily as a physical, concrete experience. Preschoolers may try to escape a procedure with verbal statements such as go away. Young school-age children may view pain as punishment for wrongdoing. This age group fears bodily harm. DIF: Cognitive Level: Analyzing REF: MCS: 865 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 4. A child, age 4 years, tells the nurse that she needs a Band-Aid where she had an injection. What nursing action should the nurse implement? a. Apply a Band-Aid. b. Ask her why she wants a Band-Aid. c. Explain why a Band-Aid is not needed. d. Show her that the bleeding has already stopped. ANS: A Children in this age grouplsfteila r that their insides ymlae ak out at ethcetioinnj site. The nurse should be prepared to apply a small Band-Aid after the injection. No explanation should be required. DIF: Cognitive Level: Understanding REF: MCS: 873 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. The psychosexual conflicts of preschool children make them extremely vulnerable to which threat? a. Loss of control b. Loss of identity c. Separation anxiety d. Bodily injury and pain ANS: D The psychosexual conflicts of children in this age group make them vulnerable to threats of bodily injury. Intrusive procedures, whether painful or painless, are threatening to preschoolers, whose concept of body integrity is still poorly developed. Loss of control, loss of identity, and separation anxiety are not related to psychosexual conflicts. DIF: Cognitive Level: Understanding REF: MCS: 873 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 6. A spinal tap must be done on a 9-yldeabro-yo. While he is waiting in the treatment room, the nurse observes that he seems composed. When the nurse asks him if he wants his mother to stay with him, he says, I am fine. How should the nurse interpret this situation? a. This child is unusually brave. b. He has learned that support does not help. c. Nine-year-old boys do not usually want a parent present during the procedure. d. Children in this age group often do not request support even though they need and want it. ANS: D The school-age childs visible composure, calmness, and acceptance often mask an inner longing for support. Children of this age have a more passive approach to pain and an indirect request for support. It is especially important to be aware of nonverbal cues such as facial expression, silence, and lack of activity. Usually when someone identifies the unspoken messages, the child will readily accept support. DIF: Cognitive Level: Analyzing REF: MCS: 866 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 7. The mother of a 7-month-old infant newly diagnosed with cystic fibrosis is rooming in with her infant. She is breastfeeding and provides all the care except for the medication administration. What should the nurse include in the plan of care? a. Ensuring that the mother has time away from the infant b. Making sure the mother is providing all of the infants care c. Determining whether other family members can provide the necessary care so the mother can rest d. Contacting the social worker because of the mothers interference with the nursing care ANS: A The mother needs sufficient treasnd nutrition so she can be effective as a caregiver. While the infant is hospitalized, the care is the responsibility of the nursing staff. The mother should be made comfortable with the care the staff provides in her caeb.seTn he mother has a right to provide care for the infant. The nursing staff and the mother should agree on the care division. DIF: Cognitive Level: Applying REF: MCS: 868 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Psychosocial Integrity 8. A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, Wait a minute, and, Im not ready. How should the nurse interpret this behavior? a. IV insertions are viewed as punishment. b. This is expected behavior for a school-age child. c. Protesting like this is usually not seen past the preschool years. d. The child has successfully manipulated the nurse in the past. ANS: B This school-age child is attempting to maintain some control over the hospital experience. The nurse should provide the girl with structured choices about when the IV line will be inserted. Preschoolers can view procedures as punishment; this is not typical behavior of a preschool-age child. DIF: Cognitive Level: Analyzing REF: MCS: 867 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. The parents of a 4-month-old infant cannot visit except on weekends. What action by the nurse indicates an understanding of the emotional needs of a young infant? a. Place her in a room away from other children. b. Assign her to the same nurse as much as possible. c. Tell the parents that frequent visiting is unnecessary. d. Assign her to different nurses so she will have varied contacts. ANS: B The infant is developing a sense of trust. This is accomplished by the consistent, loving care of a nurturing person. If the parents are unable to visit, then the same staff nurses should be used as much as possible. Placing her in a room away from other children would isolate the child. The parents should be encouraged to visit. The nurse should describe how the staff will care for the infant in their absence. DIF: Cognitive Level: Applying REF: MCS: 866 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 10. An 8-year-old girl is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. What intervention will help her most in her adjustment to the hospital? a. Explain hospital schedules to her, such as mealtimes. b. Use terms such as honey and dear to show a caring attitude. c. Explain when parents can visit and why siblings cannot come to see her. d. Orient her parents, because she is too young, to her room and hospital facility. ANS: A School-age children need to have control of their environment. The nurse should offer explanations or prepare the child for what to expect. The nurse should refer to the child by the preferred name. Explaining when parents can visit and why siblings cannot come focuses on the limitations rather than helping her adjust to the hospital. At the age of 8 years, the child should be oriented to the environment along with the parents. DIF: Cognitive Level: Applying REF: MCS: 866 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 11. A 13-year-old child with cystic fibrosis (CF) is a frequent patient on the pediatric unit. This admission, she is sleeping during the daytime and unable to sleep at night. What should be a beneficial strategy for this lcdh?i a. Administer prescribed sedative at night to aid in sleep. b. Negotiate a daily schedule that incorporates hospital routine, therapy, and free time. c. Have the practitioner speak with the child about the need for rest when receiving therapy for CF. d. Arrange a consult with the social worker to determine whether issues at home are interfering with her care. ANS: B Childrens response to the disruption of routine during hospitalization is demonstrated innega,ti sleeping, and other activities of daily living. The lack of structure is allowing the child to sleep during the day, rather than at night. Most likely the lack of schedule is the problem. The nurse and child can plan a schedule that incorporates all necessary activities,cilnuding medications, mealtimes, homework, and patient care procedures. The schedule can then be posted so tchheild has a ready reference. Sedatives are not usually usedtwh ich ildren. The child has a chronic illness and most likely knows the importance of rest. The parents and child can be questioned about changes at home since the last hospitalization. DIF: Cognitive Level: Applying REF: MCS: 869 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. Two hospitalized adolescents are playing pool in the activity room. Neither of them seems enthusiastic about the game. How should the nurse interpret this situation? a. Playing pool requires too much concentration for this age group. b. Pool is an activity better suited for younger children. c. The adolescents may be enjoying themselves but have lower energy levels than healthy children. d. The adolescents lack of enthusiasm is one of the signs of depression. ANS: C Children who are ill and hospitalized typically have lower energy levels than healthy children. Therefore, children may not appear enthusiastic about an activity even when they are enjoying it. Pool is an appropriate activity for adolescents. They have the cognitive and psychomotor skills that are necessary. If the adolescents were significantly depressed, they would be unable to engage in the game. DIF: Cognitive Level: Applying REF: MCS: 875 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13. A 6-year-old child is admitted to the pediatric unit and requires bed rest. Having art supplies available meets which purpose? a. Allows the child to create gifts for parents b. Provides developmentally appropriate activities c. Is essential for play therapy so the child can work on past problems d. Lets the child express thoughts and feelings through pictures rather than words ANS: D The art supplies allow the child to draw images that come into the mind. This can help the child develop symbols and then verbalize reactions to illness and hospitalization. The child can make gifts and drawings for parents, but the goal is to allow expression of feelings. Although art is developmentally and situationally appropriate, the child benefits by being able to express feelings nonverbally. The art supplies are not therapeutic play but a mechanism for expressive play. The child will not work on past problems. DIF: Cognitive Level: Applying REF: MCS: 874 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 14. The parents of a 3-year-old admitted for recurrent diarrhea are upset that the practitioner has not told them what is going on with their child. What is the priority intervention for this family? a. Answer all of the parents questions about the childs illness. b. Immediately the practitioner to come to the unit to speak with the family. c. Help the family develop a written list of specific questions to ask the practitioner. d. Inform the family of the time that hospital rounds are made so that they can be present. ANS: C Often families ask general questions of health care providers and do not receive the information they need. The nurse should determine what information the family does want and then help develop a list of questions. When the questions are written, the family can remember which questions to nashkaonrdctahe sheet to the practitioner for answers. The nurse may have the information the parents want, but they are asking for specific information from the practitioner. Unless it is an emergency, the nurse should not place a stat MCS: for the practitioner. Being present is not necessarily the issue but rather the ability to get answers to specific questions. DIF: Cognitive Level: Applying REF: MCS: 874 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 15. The enuisrsa dmitting a a7r-ye -old child to the pediatric unit for abdominal pain. To determine what the child understands about the reason for hospitalization, what should the nurse do? a. Find out what the parents have told the child. b. Review the note from the admitting practitioner. c. Ask the child why he came to the hospital today. d. Question the parents about why they brought the child to the hospital. ANS: C School-age children abele to answer questions. The only way for the nurse to know about the childs understanding of the reason for hospitalization is to ask the child directly. Finding out what the parents told the child and why they brought the child to the hospital or reading the admitting practitioners description of the reason for admission will not provide information about what the child has heard and retained. DIF: Cognitive Level: Applying REF: MCS: 870 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 16. The nurse is notified that a 9-year-old boy with nephrotic syndrome is being admitted. Only semiprivate rooms are available. What roommate should besetbt oescetl? a. A 10-year-old girl with pneumonia b. An 8-year-old boy with a fractured femur c. A 10-year-old boy with a ruptured appendix d. A 9-year-old girl with congenital heart disease ANS: B An 8-year-old boy with a fractured femur would be the best choice for a roommate. The boys are similar in age. The child with onephr tic syndrome most likely will be on immunosuppressive agents and susceptible to infection. The child with a fractured femur is not infectious. A girl should not be a good roommate for a school-age boy. In addition, the 10-year-old girl with pneumonia and the 10-year-old boy with a ruptured appendix have infections and could pose a risk for the child with nephrotic syndrome. DIF: Cognitive Level: Applying REF: MCS: 869 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 17. The nurse is doing a prehospitalization orientation for a girl, age 7 years, who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that after the surgery, the child will be in the intensive care unit. How might the explanation by the nurse be viewed? a. Unnecessary b. The surgeons responsibility c. Too stressful for a young child d. An appropriate part of the childs preparation ANS: D The explanation is a necessary part of preoperative preparation and will help reduce the anxiety associated with surgery. If the child wakes in the intensive care unit and is not prepared for the environment, she will be even more anxious. This is a joint responsibility of nursing, medical staff, and child life personnel. DIF: Cognitive Level: Analyzing REF: MCS: 878 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 18. A 9-year-old boy has an unplanned admission to the intensive care unit (ICU) after abdominal surgery. The nursing staff has completed the admission process, and his condition is beginning to stabilize. When speaking with the parents, the nurse should expect what additional stressor to be evident? a. Usual daynight routine b. Calming influence of staff c. Adequate privacy and support d. Insufficient remembering of his condition and routine ANS: D ICUs, especially when the family is unprepared for tahdemission, are strange and unfamiliar. There are many pieces of unfamiliar equipment, and the sights and sounds are much different from those of a general hospital unit. Also, with the childs condition being more precarious, it may be difficult to keep the parents updated on what is happening. Lights are usually on around the clock, seriously disrupting the diurnal rhythm. In most ICUs, the fsftaw orks with a sense of urgency. It is difficult for parents to ask questions about their child when staff is with other patients. Usually little privacy is available for families in ICUs. DIF: Cognitive Level: Analyzing REF: MCS: 878 TOP: NursoicnegssP:rAssessment iMenStC: Cl Needs: Psychosocial Integrity 19. A 6-year-old is being discharged home, which is 90 miles from the hospital, after an outpatient hernia repair. In addition to explicit discharge instructions, what should the nurse provide? a. An ambulance for transport home b. Verbal information about follow-up care c. Prescribed pain medication before discharge d. Driving instructions for a route with less traffic ANS: C The nurse should anticipate that the child will begin experiencing pain on the trip home. By providing a dose of oral analgesia, the nurse can ensure the child remains comfortable during the trip. Transport by ambulance is not indicated for a hernia repair. Discharge instructions should be written. The parents will be focusing on their child and returning home, which limits their ability to retain information. The parents should know the most expedient route home. DIF: Cognitive Level: Applying REF: MCS: 877 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological Integrity 20. The nurse is caring for a 10-year-old child during a long hospitalization. What intervention should the nurse include in the care plan to minimize loss of control and autonomy during the hospitalization? a. Allow the child to skip morning self-care activities to watch a favorite television program. b. Create a calendar with special events such as a visit from a friend to maintain a routine. c. Allow the child to sleep later in the morning and go to bed later at night to promote control. d. Create a restrictive environment so the child feels in control of sensory stimulation. ANS: B School-age children may feel an overwhelming loss of control and autonomy during a longer hospitalization. One rinvteention to minimize this loss of control is to create a calendar with planned special events such as a visit from a friend. Maintaining the childs daily routine is another intervention to minimize the sense of loss of control; allowing the child to skip morning self-care activities, sleep rla, te or stay up later would work against this goal. Environments should be as nonrestrictive as possible to allow the child freedom to move about, thus allowing a sense of autonomy. DIF: Cognitive Level: Applying REF: MCS: 874 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 21. The nurse is caring for a 3-year-old child during a long hospitalization. The parent is concerned about how to support the childs siblings during the hospitalization. What statement is appropriate for the nurse to make? a. You should choose one parent to spend every night in the hospital while the other parent stays at home with the other children. b. You could leave your hospitalized child for periods at night to be at home with the other children. c. You should discourage the siblings from visiting because this could upset everyone in the family. d. You could encourage a nightly phone call between the siblings as part of the bedtime routine. ANS: D A supportive measure for siblings of a hospitalized child is to have a routine of a phone call at some point during the day or evening so the parent at the hospital can stay in touch and the children at home are involved and can hear that their sibling is doing well. Parents should alternate who satat ythse hospital overnight to prevent burnout and to allow each parent time at home with the siblings. Encourage siblings to visit if appropriate to keep the family unit intact. Leaving the hospitalized child alone at night will not support the siblings at home and may cause problems with the hospitalized child. DIF: Cognitive Level: Applying REF: MCS: 877 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Itengrity 22. The nurse should expect a toddler to cope with the stress of a short period of separation from parents by displaying what? a. Regression b. Happiness c. Detachment d. Indifference ANS: A Children in the toddler stage demonstrate goal-directed behaviors when separated from parents for short periods. They may demonstrate displeasure on the parents return or departure by having temper tantrums; refusing to comply with the usual routines of mealtime, bedtime, or toileting; or regressing to more primitive levels of development. Detachment would be seen with a prolonged absence of parents, not a short one. Toddlers would not be indifferent or happy when experiencing short separations from parents. DIF: Cognitive Level: Understanding REF: MCS: 866 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 23. The nurse is providing support to parents adapting to the hospitalization of their child to the pediatric intensive care unit. The nurse notices that the parents keep asking the same questions. What should the nurse do? a. Patiently continue to answer questions, trying different approaches. b. Kindly refer them to someone else for answering their questions. c. Recognize that some parents cannot understand explanations. d. Suggest that they ask their questions when they are not upset. ANS: A In addition to a general pediatric unit, children may be admitted toisapl efc acilities such as an ambulatory or outpatient setting, an isolation room, or intensive care. Wherever the location, the core principles of patient and family-centered care provide a foundation for all communication and interventions with the patient, family, and health care team. The nurse should do the therapeutic action and patiently continue to answer questions, trying different approaches. DIF: Cognitive Level: Applying REF: MCS: 878 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Integrity 24. The nurse is instructing student nurses about the stress of hospitalization for children from middle infancy throughout the preschool years. What major stress should the nurse relate to the students? a. Pain b. Bodily injury c. Loss of control d. Separation anxiety ANS: D The major stress from middle infancy throughout the preschool years, especially for children ages 6 to 30 months, is separation anxiety. DIF: Cognitive Level: Applying REF: MCS: 864 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 25. Parents of a hospitalized child often question the skill of staff. The nurse interprets this behavior by the parents as what? a. Normal b. Paranoid c. Indifferent d. Wanting attention ANS: A Recent research has identified oconmt m hemes among parents whose children were hospitalized, including ifneegl an overall sense of helplessness, qiouneisntg t he skills of staff, accepting the reality of hospitalization, needing to have information explained in simple language, dealing with fear, coping with uncertainty, and seeking reassurance from the health care team. The behavior does not indicate the parents are paranoid, indifferent, or wanting attention. DIF: Cognitive Level: Analyzing REF: MCS: 868 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Itengrity 26. When a preschool-age child is hospitalized without adequate preparation, the nurse should recognize that the child may likely see hospitalization as what? a. Punishment b. Loss of parental love c. Threat to the childs self-image d. Loss of companionship with friends ANS: A The rationale for preparing children for the hospital experience and related procedures is based on the principle that a fear of the unknown (fantasy) exceeds fear of the known. Preschool-age children see hospitalization as a punishment. Loss of parental love would be a toddlers reaction. Threat to the lcdhsi self-image would be a school-age childs reaction. Loss of companionship with friends would be an adolescents reaction. DIF: Cognitive Level: Analyzing REF: MCS: 878 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Itengrity 27. A parent nteoeldesave a hospitalized todd ler for a short period of time. What action should the nurse suggest to the parent to ease the separation for the toddler? a. Bring a new toy when returning. b. Leave when the child is distracted. c. Tell the child when they will return. d. Leave a favorite article from home with the child. ANS: D If the parents cannot stay with the child, they should leave favorite articles from home with the child, such as a blanket, toy, bottle, feeding utensil, or article of clothing. Because young children associate such inanimate objects with significant people, they gain comfort and reassurance from these possessions. They make the association that if the parents left this, the parents will surely return. Bringing a new toy would not help with the separation. The parent should not leave when the child is distracted, and toddlers would not understand when the parent should return because time is not a concept they understand. DIF: Cognitive Level: Applying REF: MCS: 872 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 28. The nurse needs to masosensths -aol15- d child who is sitting quietly on his fathers lap. What initial action by the nurse would be most appropriate? a. Ask the father to place the child on the exam table. b. Undress the child while he is still sitting on his fathers lap. c. Talk softly to the child while taking him from his father. d. Begin the assessment while the child is in his fathers lap. ANS: D For young children, particularly infants and toddlers, preserving parentchild contact is a good way of decreasing stress or the need for physical restraint during an assessment. For example, much of a patients physical examination can be done with the patient in a parents lap with the parent providing reassuring and comforting contact. The initial action would be to begin the assessment while the child is in his fathers lap. DIF: Cognitive Level: Applying REF: MCS: 873 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 29. What parents should have the tmdoisfficul t time coping with their childs ihtoalsipzation? a. Parents of a child hospitalized for juvenile arthritis b. Parents of a child hospitalized with a recent diagnosis of bronchiolitis c. Parents of a child hospitalized for sepsis resulting from an untreated injury d. Parents of a child hospitalized for surgical correction of undescended testicles ANS: C Factors that affect parents reactions to their childs illness include the seriousness of eththreat to the child. The parents of a child hospitalized for sepsis resulting from an untreated injury would have more difficulty coping because of the seriousness of the illness and because the wound was not treated immediately. DIF: Cognitive Level: Analyzing REF: MCS: 868 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 30. What choice of words or phrases would be inappropriate to use with a child? a. Rolling bed for stretcher b. Special medicine for dye c. Make sleepy for deaden d. Catheter for intravenous ANS: D Children can grasp information only if it is presented on or close to their level of cognitive development. cTehsissitnaetes an awareness of the words used toidbescr events or oprcesses, and exploring family traditions or approaches to information sharing and creating patient specific language or context. Therefore, toepvrent or alleviate fears, nurses must be aware of the medical terminology and vocabulary that they use every day and be sensitive to the use of slang or confusing terminology. Catheter is a medical term and would be confusing. DIF: Cognitive Level: Applying REF: MCS: 873 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 31. The nurse is assessing a childs functional self-care level for feeding, bathing and hygiene, dressing, and grooming and toileting. The child requires assistance or supervision from another person and equipment or device. What code does the nurse assign for this child? a. I b. II c. III d. IV ANS: C A code of III indicates the child requires assistance from another person and equipment or device. A code of I indicates use of equipment or device. A code of IIciantdeis assistance or supervision from another person. A code of IV indicates the child is totally dependent. DIF: Cognitive Level: Analyzing REF: MCS: 870 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. What are signs and symptoms of the stage of despair in relation to separation anxiety in young children? (Select all that apply.) a. Withdrawn from others b. Uncommunicative c. Clings to parents d. Physically attacks strangers e. Forms new but superficial relationships f. Regresses to early behaviors ANS: A, B, F Manifestations of the stage of despair seen in children during a hospitalization may include withdrawing from others, being uncommunicative, and regressing to earlier behaviors. Clinging to parents and physically attacking a stranger should be seen during the stage of protest, and forming new but superficial relationships is seen during the stage of detachment. DIF: Cognitive Level: Applying REF: MCS: 865 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 2. What influences a childs reaction to the stsroers of hospitalization? (Select all that apply.) a. Gender b. Separation c. Support systems d. Developmental age e. Previous experience with illness ANS: B, C, D, E Major stressors of hospitalization pinacrlautidoens, eloss of control, bodily injury, and pain. Childrens reactions to these crises are influenced by their developmental age; previous experience with illness, separation, or hospitalization; innate and acquired coping skills; seriousness of the diagnosis; and support systems available. Gender does not have an effect on a childs reaction to stressors of hospitalization. DIF: Cognitive Level: Understanding REF: MCS: 867 TOP: Nursing Process: Assessment :MCSC lient Needs: Psychosocial Integrity 3. The parents tell a nurse our child is having some short-term negative outcomes since the hospitalization. The nurse recognizes that what can negatively affect short-term negative outcomes? (Select all that apply.) a. Parents anxiety b. Consistent nurses c. Number of visitors d. Length of hospitalization e. Multiple invasive procedures ANS: A, D, E The stressors of hospitalization may cause young children to experience short- and long-term negative outcomes. Adverse outcomes may be related to the length and number of admissions, multiple invasive procedures, and the parents anxiety. Consistent nurses would have a positive effect on short-term negative outcomes. The number of visitors does not have an effect on negative outcomes. DIF: Cognitive Level: Understanding REF: MCS: 867 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 4. What are signs and symptoms of the stage of detachment in relation to separation anxiety in young children? (Select all that apply.) a. Appears happy b. Lacks interest in the environment c. Regresses to an earlier behavior d. Forms new but superficial relationships e. Interacts with strangers or familiar caregivers ANS: A, D, E Manifestations of the stage of detachment seen in children during a hospitalization may include appearing happy, forming new but superficial relationships, and interacting with strangers or familiar caregivers. Lacking interest in the environment and regressing to an earlier behavior are manifestations seen in the stage of despair. DIF: Cognitive Level: Applying REF: MCS: 864 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 5. What factors influence the effects of a childs hospitalization on siblings? (Select all that apply.) a. Older siblings b. Experiencing minimal changes c. Receiving little information about their ill brother or sister d. Being cared for outside the home by care providers who are not relatives e. Perceiving that their parents treat them differently compared with before their siblings hospitalization ANS: C, D, E Various factors have been identified that influence the effects of a childs hospitalization on siblings. Factors that are related specifically to itthael heoxspp erience and increase the effects on the sibling are being cared for outside the home by care providers who are not relatives, receiving little minafotiron about their ill brother or sister, and perceiving that their parents treat them differently compared with before their siblings hospitalization. Being younger, not older, and experiencing many nchgaes, not minimal changes, are factors that influence the effects of a childs hospitalization on siblings. DIF: Cognitive Level: Analyzing REF: MCS: 868 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 6. What factors can negatively affect parents reactions to their childs illness? (Select all that apply.) a. Additional stresses b. Previous coping abilities c. Lack of support systems d. Seriousness of the threat to the child e. Previous experience with hospitalization ANS: A, C, D The factors that can negatively affect parents reactions to their childs illness are additional stresses, lack of support systems, and the seriousness of the threat to the child. Previous coping abilities and previous experience with hospitalization would have a positive effect on coping. DIF: Cognitive Level: Understanding REF: MCS: 868 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 7. The nurse is assessing a familys use of complementary medicine practices.aWt phractices are classified as mindbody control therapies? (Select all that apply.) a. Relaxation b. Acupuncture c. Prayer therapy d. Guided imagery e. Herbal medicine ANS: A, C, D Relaxation, prayer therapy, and guided imagery are classified as mindbody control therapies. Acupuncture and herbal medicine are classified as traditional and ethnomedicine therapies. DIF: Cognitive Level: Analyzing REF: MCS: 872 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 8. The nurse is assessing a familys use of complementary medicine practices.aWt phractices are classified as nutrition, diet, and lifestyle or behavioral health changes? (Select all that apply.) a. Reflexology b. Macrobiotics c. Megavitamins d. Health risk reduction e. Chiropractic medicine ANS: B, C, D Macrobiotics, megavitamins, and health risk reduction are classified as nutrition, diet, and lifestyle or vbeiohraal he alth changes. Reflexology and chiropractic medicine are classified as structural manipulation and energetic therapies. DIF: Cognitive Level: Analyzing REF: MCS: 872 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Health Promotion and Maintenance 9. Parents tell the nurse that siblings of their hospitalized child are feeling left out.aWt h suggestions should the nurse make to tphaerents to assi st the siblings to at dtojutshe hospitalization of their brother or sister? (Select all that apply.) a. Arrange for visits to the hospital. b. Limit information given to the siblings. c. Encourage phone calls to the hospitalized child. d. Make or buy inexpensive toys or trinkets for the siblings. e. Identify an extended family member to be their support system. ANS: A, C, D, E Strategies to support siblings during hospitalization include arranging for visits, encouraging phone calls, giving inexpensive gifts, and identifying a support person. Information should be shared with the siblings not limited. DIF: Cognitive Level: Applying REF: MCS: 877 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Psychosocial 1In0t.eWgrihtayt are core principles of patient- and family-centered care? (Select all that apply.) a. Collaboration b. Empowering families c. Providing formal and informal support d. Maintaining strict policy and procedure routines e. Withholding information that is likely to cause anxiety ANS: B, C Core principles of patent- and family-centered care include collaboration, empowerment, and providing formal and informal support. There should be flexibility in policy and procedures, and communication should be complete, honest, and unbiased, not withheld. DIF: Cognitive Level: Understanding REF: MCS: 880 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 11. The nurse relates to parents trheaatrtehseome beneficial effects of hospitalization for their child. What are beneficial effects of hospitalization? (Select all that apply.) a. Recovery from illness b. Improve coping abilities c. Opportunity to master stress d. Provide a break from school e. Provide new socialization experiences ANS: A, B, C, E The most obvious benefit is the recovery from illness, but hospitalization also can present an opportunity for children to master stress and feel competent in their coping abilities. The hospital environment can provide children with new socialization experiences that can broaden their interpersonal relationships. Having a break from school is not a benefit of hospitalization. DIF: Cognitive Level: Applying REF: MCS: 867 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Psychosocial Integrity 12. What nursing interventions should the nurse plan for a hospitalized toddler to minimize fear of bodily injury? (Select all that apply.) a. Perform procedures slowly. b. Maintain parentchild contact. c. Use progressively smaller dressings on surgical incisions. d. Tell the child bleeding will stop after the needle is removed. e. Remove a dressing as quickly as possible from surgical incisions. ANS: B, C Whenever procedures are performed on young children, the most supportive intervention to minimize the fear of bodily injury is to do the procedure as quickly as possible while maintaining parentchild contact. Because of toddlers and preschool childrens poorly defined body boundaries, the use of bandages may be particularly helpful. For example, telling children that the bleeding will stop after the needle is removed does little to relieve their fears, but applying a small Band-Aid usually reassures them. The size of bandages is also significant to children in this age group; the larger the bandage, the more importance is attached to the wound. Watching their surgical dressings become successively smaller is one way young children can measure healing and improvement. Prematurely removing a dressing may cause these children considerable concern for their well-being. Chapter 22.Pediatric Nursing Interventions and Skills MULTIPLE CHOICE 1. A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source? a. Herself b. Her mother c. Court order d. Legal guardian ANS: A Contraceptive advice is one of the conditions that is considered medically emancipated. The adolescent is able to provide her own informed consent. DIF: Cognitive Level: Applying REF: MCS: 884 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation? a. Tell him that this procedure will help him get well faster. b. Take his blood pressure when a parent is there to comfort him. c. Explain to him how the blood flows through the arm and why the blood pressure is important. d. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place. ANS: D A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure in simple terms and allow the child to see how the equipment works. This will helplaly f ares of bodily harm. Blood pressure measurement is used for assessment, not therapy, and will not help him get well faster. Although the parent will be able to support the child, he may still be uncooperative. Also, the assessment of blood pressure may be needed before the parent is available. Explaining to a preschooler how the blood flows through the artery and why the blood pressure is important is too complex. DIF: Cognitive Level: Understanding REF: MCS: 886 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion andiMnteanance 3. A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?? a. Allow her to wear her underpants. b. Discuss with her mother why this is important to the child. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy. ANS: A It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means. DIF: Cognitive Level: Applying REF: MCS: 887 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. Using knowledge of child development, what approach is best when preparing a toddler for a procedure? a. Avoid asking the child to make choices. b. Plan for a teaching session to last about 20 minutes. c. Demonstrate on a doll how the procedure will be done. d. Show the necessary equipment without allowing child to handle it. ANS: C Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the childs favorite doll because the toddler may think the doll is really feeling the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it. DIF: Cognitive Level: Applying REF: MCS: 887 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse? a. Explain that it will not be painful. b. Suggest to him that he not worry about losing just a little bit of blood. c. Discuss with him how his body is always in the process of making blood. d. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure. ANS: C School-age children can understand othoadt cbal n be replaced. Explain the procedure to him using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to worry will not allay his fears. DIF: Cognitive Level: Applying REF: MCS: 907 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond? a. Holding your child is unsafe. b. Holding may help your child relax. c. Hospital policy prohibits this interaction. d. Holding your child is unnecessary given the childs age. ANS: B The mothers preference for iansgsi,st observing, or waiting outside the room should be assessed, as well as the childs preference for epnartal pr esence. The childs choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care. DIF: Cognitive Level: Applying REF: MCS: 907 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 7. A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do? a. Give him a large cup with ice so it tastes better. b. Restrict him to his room until he drinks the GoLYTELY. c. Use little cups and make a game to reward him for each cup he drinks. d. Tell him that if he does not finish drinking by a set time, the practitioner will be angry. ANS: C One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another MCS: of a book) is given for each cup. A large cup of ice would make it more difficult because the child would see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would kmeolystnliot be effective. DIF: Cognitive Level: Applying REF: MCS: 915 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention? a. Administering preoperative antibiotic b. Verifying that the child and procedure are correct c. Ensuring that the toddler has been NPO since midnight d. Informing the parents where they can wait during the procedure ANS: B The most important intervention is to ensure that rthecetcor child is going to the operating room for the identified procedure. It is the snpuorsnessibrielity to v erifytifiecnation of the lcdhia nd what procedure is to be done. If an antibiotic is ordered, administering pitoirstaimnt , but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction. DIF: Cognitive Level: Applying REF: MCS: 915 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 9. A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively. What shouldhbeenturses next action? a. Follow the orders and check in 2 hours. b. Ask the parents if this is the childs usual heart rate. c. Recheck the pulse and blood pressure in 15 minutes. d. Notify the surgeon that the child is probably going into shock. ANS: C In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the childs condition is stable. When a disparity in vital signs or other assessment adaits observed, the nurse should reassess sooner. Most parents will not know their childs heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status. DIF: Cognitive Level: Applying REF: MCS: 892 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. A 10-year-old child requires daily medications faorc hronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen? a. Establish a contract with her, including rewards. b. Suggest time-outs when she forgets her medicine. c. Discuss with her mother the damaging effects of her rescuing the child. d. Ask the child to bring her medicine containers to each appointment so they can be counted. ANS: A Many factors can contribute to the childs not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself. DIF: Cognitive Level: Applying REF: MCS: 891 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Psychosocial I1n1t.eAgri7ty-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include? a. Massaging reddened bony prominences b. Teaching the parents to turn the child every 4 hours c. Ensuring that nutritional intake meets requirements d. Minimizing use of extra linens, which can irritate the childs skin ANS: C Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This should be avoided. Although parents can participate, turning the iclhd is tehserenu rs sponsibility. If the child is alert and can move, position shifts should be done more frequently. If the child does not move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child should not be dragged across the sheet. Children should be lifted and moved to avoid friction and shearing. DIF: Cognitive Level: Applying REF: MCS: 896 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at the end of every meal that he eats. ANS: A Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, the nurse should request favorite foods for the child. The foods he likes provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment. DIF: Cognitive Level: Applying REF: MCS: 897 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13. A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal? a. Tolerated breakfast well b. Finished all of breakfast ordered c. One pancake, eggs, and 240 ml OJ d. No documentation is needed for this age child. ANS: C Specific information is necessary for hospitalized children. It is essential to be able to identify caloric intake and eating patterns for assessment and intervention purposes. That he tolerated breakfast well only provides information that the child did not become ill with the meal. Even if he finished all his breakfast, an evaluation cannot be completed unless the quantity of food orderend. is know Nutritional information is essential, especially fcohrildren w ith rcohnic illnesses. DIF: Cognitive Level: Applying REF: MCS: 897 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Physiological Integrity 14. A child, sa,ghea7s yaefaerver a ssociated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child? a. Relief of discomfort b. Reassurance that illness is temporary c. Prevention of secondary bacterial infection d. Avoidance of life-threatening complications ANS: A The principal reason for treating fever is the relief of discomfort. Relief measures include pharmacologic and environmental intervention. The most effective is the use of mphaacrologic agents to lower the set point. Although the nurse can reassure the child that the illness is temporary, the child is often uncomfortable and irritable. Intervention helps the child and family minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life- threatening events are associated with fever. The use of antipyretics does not seem to reduce the incidence of febrile seizures. DIF: Cognitive Level: Analyzing REF: MCS: 899 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 15. A critically ill child has hyperthermia. The nptasrea ksthe nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents? a. Febrile seizures can result. b. Antipyretics may cause malignant hyperthermia. c. Antipyretics are of no value in treating hyperthermia. d. Liver damage may occur in critically ill children. ANS: C Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver is already compromised. Other antipyretics are available, but they are of no value in hyperthermia. DIF: Cognitive Level: Applying REF: MCS: 899 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I1n6t.eTgrhietynurse gives an injection in a patients room. How should the nurse dispose of the needle? a. Remove the needle from the syringe and dispose of it in a proper container. b. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room. c. Close the safety cover on the needle and return it to the medication preparation area for proper disposal. d. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room. ANS: B All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof container located near the site of use. Consequently, these containers should be installed in the patients room. Needles and syringes are disposed of uncapped and unbroken. A used needle should not be transported to an area distant from use for disposal. DIF: Cognitive Level: Understanding REF: MCS: 903 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 17. A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions? a. Droplet b. Contact c. Airborne d. Standard ANS: B MRSA is an increasingly significant source of ahlospit -acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aureus gisanistman or that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism. DIF: Cognitive Level: Applying REF: MCS: 902 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 18. An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can ebme roved. What nurses response is best? a. Restraints need to be koenpt all the time. b. That is fine as long as you are with him. c. That is fine if we have his parents consent. d. The restraints can be off only when the nursing staff is present. ANS: B The restraints are necessary to protect the IV site. If tchheild has appropriate supervision, restraints are not snseacrey. The nurse should remove the restraints whenever possible. When parents or staff members are present, the restraints can be removed and the IV site protected. Parental permission is not needed for restraint removal. DIF: Cognitive Level: Applying REF: MCS: 903 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19. A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care? a. Use an 18-gauge needle if possible. b. Show the child the equipment to be used before the procedure. c. If not successful after four attempts, have another nurse try. d. Restrain the child completely. ANS: B To provide atraumatic care the child should be able to see the equipment to be used before the procedure begins.hUessemtallest gauge needle that p meirts free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four upruensc,talternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging. DIF: Cognitive Level: Applying REF: MCS: 886 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do? a. Set up a tray with equipment the same size as for adults. b. Apply EMLA to the puncture site 15 minutes before the procedure. c. Prepare the child for conscious sedation being used for the procedure. d. Reassure the parents that the test is simple, painless, and risk free. ANS: C Because of the urgency of the childs condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap precludes its use. A spinal tap is not a simple procedure and does have associatedsrkis; an algesia will be given for the pain. DIF: Cognitive Level: Applying REF: MCS: 907 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 21. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests? a. Apply a urine collection bag to the perineal area. b. Tape a small medicine cup inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe without a needle. d. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper. ANS: C To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the childs skin. It is not feasible to tape a sm the cup. ll medicine cup to the inside of pthee dia r; the urine lwl is llpfirom DIF: Cognitive Level: Applying REF: MCS: 908 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 22. A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample? a. Perform a new venipuncture to obtain the blood sample. b. Interrupt the IV fluid and withdraw the blood sample needed. c. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. d. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample. ANS: C The blood specimen obtained must reflect the appropriate hemodilution of the blood and electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device and discard it. The nseaxmt ple w ill come from the childs circulating blood. With a ncetral venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be diluted with either the IV fluid being administered or the saline. DIF: Cognitive Level: Applying REF: MCS: 921 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23. The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do next? a. Keep the childs arm extended while applying a Band-Aid to the site. b. Keep the childs arm extended and apply pressure to the site for a few minutes. c. Apply a Band-Aid to the site and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes. ANS: B Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage or gauze pad is applied. DIF: Cognitive Level: Applying REF: MCS: 912 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 24. An appropriate method for administering oral medications that aretebit child should be to mix them with which? a. Bottle of formula or milk b. Any food the child is going to eat c. One teaspoon of something sweet-tasting such as jam d. Carbonated beverage, which is then poured over crushed ice ANS: C r to an infant or small Mix the drug with a small amount (about 1 tsp) of sweet-tasting substance. This will make the medication more palatable to itlhde. cThhe medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat this food in the future. DIF: Cognitive Level: Applying REF: MCS: 915 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the medicine? a. A measuring spoon should be used, and the medication must be given every 6 hours. b. The mother is not able to handle this regimen. Long-acting intramuscular antibiotics should be administered. c. A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake. d. A household teaspoon should be used and the medicine given when the child wakes up, around lunch time, at dinner time, and before bed. ANS: C A hollow-handled medication spoon allows the mother to measure the correct amount of medication. The order is written for four times a day; every 6 hours dosing is not necessary. There is no indication that the mother is not able to adhere to the medication regimen. She is asking for clarification so she can properly care for her child. Long-acting intramuscular antibiotics are not indicated. Household teaspoons vary greatly and should not be used. DIF: Cognitive Level: Applying REF: MCS: 915 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n6t.eGgruitiydelines for intramuscular administration of medication in school-age children include what standard? a. Inject medication as rapidly as possible. b. Insert needle quickly, using a dartlike motion. c. Have the child stand if at all possible and if the child is cooperative. d. Penetrate the skin immediately after cleansing the site while the skin is moist. ANS: B The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before the skin is penetrated. Place the child in a lying or sitting position. DIF: Cognitive Level: Applying REF: MCS: 920 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 27. What is an advantage of the ventrogluteal muscle as an injection site in young children? a. Easily accessible from many directions b. Free of significant nerves and vascular structures c. Can be used until child reaches a weight of 9 kg (20 lb) d. Increased subcutaneous fat, which provides sustained drug absorption ANS: B Being efre of si gnificant nerves and vascular structure is one of the advantages of the ventrogluteal site. In addition, it is considered less painful than the tvuass lateralis. The jmoar disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The vastus lateralis is a more accessible site.eTh ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical guidelines address the need for tchheild t oablkeiwng. The site has less subcutaneous tissue, which facilitates intramuscular deposition of the drug rather than subcutaneous. DIF: Cognitive Level: Analyzing REF: MCS: 919 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 28. When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a. At the lacrimal duct b. On the sclera while the child looks to the outside c. In the conjunctival sac when the lower eyelid is pulled down d. Carefully under the eyelid while it is gently pulled upward ANS: C The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug. DIF: Cognitive Level: Applying REF: MCS: 931 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n9t.eWgrihtayt is the best method to verify the placement of a nasogastric tube before each use? a. Radiologic confirmation b. Auscultation of injected air c. Aspiration of stomach contents d. Verification of tape placement on tube ANS: C Visual inspection and pH check of stomach contents is a reliable method of determining placement before each use. Radiologic examination should be obtained after initial placement but would be too cumbersome to do before each use. Auscultation is an unreliable method to confirm tube placement because of the similarity of sounds produced by air in the bronchus, esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the tube has moved within the tape or become dislodged from the stomach. DIF: Cognitive Level: Applying REF: MCS: 935 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 30. Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G- tube). What is essential information for the parents to receive? a. Verify placement before each feeding. b. Use a syringe with a plunger to give the infant bolus feedings. c. Position the infant on the right side during and after the feeding. d. Beefy red tissue around the G-tube site must be reported to the practitioner. ANS: C Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by gravity flow. The plunger may be used to initiate the feeding, but then the formula should be allowed to flow. Beefy red tissue around the G-tube site is normal granulation tissue that is expected. DIF: Cognitive Level: Applying REF: MCS: 935 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I3n1t.eWgrihtayt is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease? a. Teaching how to irrigate the colostomy b. Protecting the skin around the colostomy c. Discussing the implications of a colostomy during puberty d. Using simple, straightforward language to prepare the child ANS: B Protection of the peristomal skin is a major priority. Well-fitting appliances and skin protectants are used. Teaching how to irrigate a colostomy is not necessary because colostomies are not irrigated in infants. The colostomy is usually reversed within 6 months to 1 year. The parents, not the infant, need to be prepared for the surgery. DIF: Cognitive Level: Applying REF: MCS: 940 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 32. A 1-month-old infant is admitted thoe t hospital. The infants mother is 17 years old and single and lives with her parents. Who signs the informed consent for the 1-month-old infant? a. The infants mother b. The maternal grandparents of the infant c. The paternal grandparents of the infant d. Both the infants mother and the maternal grandparents ANS: A An emancipated minor is one who is legally under the age of majority but is recognized as having the legal capacity of an adult under cuirmstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service. DIF: Cognitive Level: Analyzing REF: MCS: 884 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 33. A preschool child needs a dressing change. To prepare the child, what strategy should the nurse implement? a. Explain the procedure using medical terminology. b. Plan a 30-minute teaching session. c. Give choices when possible but avoid delay. d. Allow time after the procedure for questions and discussion. ANS: C Involving children helps to gain their cooperation. Permitting choices gives them some measure of control. The other options would not be appropriate for a preschool child. DIF: Cognitive Level: Applying REF: MCS: 886 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 34. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics.tWguhia deline is accurate? a. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed. b. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur. c. Discourage parent presence during procedures on infants and toddlers. d. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child. ANS: D To assist the school-age child in meeting Ericksons developmental stage of industry, using simple diagrams of anatomy and physiology to explain a procedure is the accurate guideline. Toddlers should be told about a procedure right before the procedure. School-age children should know about the procedure in advance, not right before, and parents should be present for procedures for infants and toddlers. DIF: Cognitive Level: Applying REF: MCS: 887 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 35. A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying loudly. The nurse should take which action? a. Have the lab technician stop the procedure until the child stops crying. b. Do nothing. Its Okay for a child to cry during a painful procedure. c. Tell the child to stop crying; its only a small prick. d. Tell the child to stop crying because the procedure is almost over. ANS: B The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. It is natural for children toestoruikt in frustration or to try to avoid stress-provoking situations. The child needs to know that it is all right to cry. DIF: Cognitive Level: Applying REF: MCS: 889 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 36. At which age should a nurse keep teaching time short (5 minutes)? a. Infant b. Toddler c. Preschool d. School age ANS: B Toddlers have limited time concept, and teaching time should be kept short (510 minutes). DIF: Cognitive Level: Applying REF: MCS: 883 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Health Promotion and Maintenance 37. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate? a. Retake the temperature in 15 minutes after giving the Tylenol. b. Place a warm blanket on the child so chilling does not occur. c. Check to be sure the Tylenol dose does not exceed 15 mg/kg. d. Use cold compresses instead of Tylenol to control the fever. ANS: C Nurses must have an understanding of the safe dosages of medications they administer to children, as well as the expected actions, possible side effects, and signs of toxicity. The recommended doses of acetaminophen should never be exceeded. DIF: Cognitive Level: Applying REF: MCS: 899 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 38. The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old infant. What should the length of the needle and amount to be given be? a. 5/8 to 1 inch; 0.5 to 1.0 ml b. 1 inch to 1 1/2 inch; 1.0 to 2.0 ml c. 1 inch to 1 1/2 inch; 0.5 to 1.0 ml d. 5/8 to 1 inch; 0.75 to 2 ml ANS: A The length of a needle for an infant should be 5/8 to 1 inch, and the amount of solution should not exceed 1 ml. DIF: Cognitive Level: Applying REF: MCS: 917 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 39. The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The lcdhis tarts to cry and tells the nurse, Do it later, okay? What action should the nurse take? a. Postpone starting the IV until the next shift. b. Start the IV line and then allow for expression of feelings. c. Change the route of the antibiotics to PO. d. Postpone starting the IV line until the child is ready. ANS: B A school-age child may try to delay the procedure, but it is best to complete the procedure and allow time for the child to express his or her feelings. The nurse should not postpone administering the antibiotic, change it to PO, or wait to start the IV line until the child is ready. DIF: Cognitive Level: Applying REF: MCS: 889 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 40. The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What is the first thing the nurse should do? a. Check placement of the tube. b. Check the pH of the gastric aspirate. c. Flush the tube with a small amount of water. d. Give the medication and then flush with a small amount of water. ANS: B The most accurate way to check the position of the nasogastric tube is by checking the pH. Auscultation as a verification tool is reliable only 60% to 80% of the time and should not be used without additional methods. The tube should not be flushed or the medication administered until placement of the tube is checked. DIF: Cognitive Level: Applying REF: MCS: 936 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 41. To facilitate the administration of an oral medication to a preschool-age child, what action should the nurse take? a. Dilute the medication in a large amount of favorite liquid and allow the child to hold the cup. b. Set limits about the need to take medication and offer praise immediately after the task is accomplished. c. Mix the medication in a moderate amount of the childs favorite food. d. Explain the purpose of the medication and allow the child time to express resistance before giving the medication. ANS: B Nurses who approach children with confidence and who convey the impression that they expect to be successful are less likely to encounter difficulty. It is best to approach a child as though cooperation is expected. Tdihceatmioen should not be placed in a favorite liquid or food. Allowing the child time to express resistance will delay administration of the medication. DIF: Cognitive Level: Applying REF: MCS: 887 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 42. A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing intervention should be implemented for the child? a. Hold the child while rocking in a chair after each injection. b. Prepare the child several hours before the injection is given. c. Allow the child to watch a younger child receive an injection. d. Encourage the child to draw a picture of the pain experienced when an injection is given. ANS: A After the procedure, the child continues to need reassurance that he or she performed well and is accepted and loved. The other options are not appropriate for a toddler. DIF: Cognitive Level: Applying REF: MCS: 889 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 43. When checking the intravenous (IV) site on a child, the nurse should take which action? a. Look at the site. b. Ask the child if the site hurts. c. Look at the site while palpating the area. d. Take all the tape off, assess the site, and redress. ANS: C To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the area. The other options would not be adequate assessments of the site. DIF: Cognitive Level: Applying REF: MCS: 918 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What interventions should be included in the childs care plan? (Select all that apply.) a. Place a call light and desired items within reach. b. Keep the bed in the highest position with the two side rails up. c. Turn off the lights and television at night. d. Keep personal belongings and clutter contained in one area of the floor. e. Have the child wear an appropriate-size gown and nonskid footwear. ANS: A, E Prevention of falls requires alterations in the environment, including keeping call light and desired items within reach and having the child wear appropriate-size gowns and nonskid footwear. The bed should be in the lowest position possible with all the side rails up; at least a dim light should be left on at night; and personal belongings and clutter should not be on the floorthey should be in a cabinet. DIF: Cognitive Level: Applying REF: MCS: 901 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 2. What methods should the nurse use to measure compliance to a treatment plan? (Select all that apply.) a. Pill counts b. Chemical assays c. Direct observation d. Third-party reporting e. Monitoring therapeutic response ANS: A, B, C, E Assessment of pcolimance must i lundce direct m easurement qteucehsn.iP ill counts, chemical assays, direct observation, taonrdinmgotni herapeutic response are direct measurement techniques. Third-party reporting would not always be available and would not be a method to measure compliance. DIF: Cognitive Level: Applying REF: MCS: 894 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 3. What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? (Select all that apply.) a. Nutrition consults b. Using skin moisturizers c. Turning the child every 2 hours d. Using plastic disposable underpads e. Using draw sheets to minimize shear ANS: A, B, C, E Intervoennsti found to prevent pressure ulcers in critically ill children include nutrition consults, using skin moisturizers, turning the child every 2 hours, and using draw sheets to minimize shear. Dryweave underpads, not underpads with plastic, should be used to reduce moisture. DIF: Cognitive Level: Applying REF: MCS: 896 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. The nurse is preparing to obtain a nasal washing from a child. What equipment should the nurse gather for the procedure? (Select all that apply.) a. Sterile water b. A sterile swab c. Syringe with tubing d. Sterile normal saline e. Tracheal suction catheter ANS: C, D Nasal washings may be obtained to identify viral pathogens and guide therapy in some respiratory conditions. The child is placed supine, and 1 to 3 ml of sterile normal saline is instilled with a sterile syringe t(hwoiut a ne dlee ) into one nostril. The tceonnts are a spirated with a syringe with 5 cm (2 inches) of 18- to 20-gauge tubing. The saline is quickly instilled and then aspirated to recover the nasal specimen. A tracheal suction catheter would not trap the mucus. Normal saline is used, not sterile water. A sterile swab is used for a throat culture, not for nasal washings. DIF: Cognitive Level: Applying REF: MCS: 914 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5. The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.) a. The child has a stiff neck. b. The fever is over 40.6 C (105 F). c. The child is younger than 2 months. d. The fever has lasted for more than 3 days. e. The fever went away for more than 24 hours and then returned. ANS: A, B, C Parents should call the office immediately lidf ahacshi a fever over 40.6 C (105 F), the child is younger than 2 months, or the child has a stiff neck. Parents are to call within 24 hours if the fever went away for more than 24 hours and then returned or the fever has lasted for more than 3 days. DIF: Cognitive Level: Applying REF: MCS: 900 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. What strategies should the nurse implement to assist in feeding a sick child? (Select all that apply.) a. Serve large portions. b. Make mealtimes pleasant. c. Avoid foods that are highly seasoned. d. Provide finger foods for young children. e. Ensure a variety of foods, textures, and colors. ANS: B, C, D, E To assist in feeding a sick child mealtimes should be pleasant; highly seasoned foods should be avoided; finger foods should be provided for young children; and a variety of foods, textures, and colors should be ensured. Small portions, not large, should be served. DIF: Cognitive Level: Applying REF: MCS: 898 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. What disease processes require contact isolation? (Select all that apply.) a. Rotavirus b. Hepatitis A c. Streptococcal pharyngitis d. Mycoplasmal pneumonia e. Respiratory syncytial virus ANS: A, B, E In addition to Standard Precautions, use contact precautions for patients known or suspected to have serious linl esses easily atrnsmitted by diecrt pa tient contact or by contact with items in the patients environment. Examples of such illnesses include rotavirus, hepatitis A, and respiratory syncytial virus. Streptococcal pharyngitis and mycoplasmal pneumonia require droplet precautions. DIF: Cognitive Level: Analyzing REF: MCS: 902 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 8. What disease processes require airborne precautions? (Select all that apply.) a. Measles b. Varicella c. Pertussis d. Meningitis e. Tuberculosis ANS: A, B, E In addition to Standard Precautions, use airborne precautions for patients known or suspected to have serious linl esses transmitted by airborne droplet nuclei. Examples of suchlinlesses include measles, varicella (including disseminated zoster), and tuberculosis. Pertussis and meningitis require droplet precautions. DIF: Cognitive Level: Analyzing REF: MCS: 902 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 9. What are the advantages of panlainmted po rt a(Ptho)r?t-(aS-eClect all that apply.) a. Reduced risk of infection b. Reduced cost for the family c. Placed completely under the skin d. Easy to use for self-administered infusions e. Removal does not require a surgical procedure ANS: A, B, C The advantages of an implanted port include reduced risk of infection, reduced cost for the family, and placed completely under tchaeussekiint .isBiemplanted an dcmesussetdb, e ac it is not easy to use for self-administered infusions, and removal does require a surgical procedure. DIF: Cognitive Level: Analyzing REF: MCS: 921 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 10. What play activities should tnhuerse implement toreangceofuluid intake for a child? (Select all that apply.) a. Have a tea party. b. Use a crazy straw. c. Cut gelatin into fun shapes. d. Place liquid in large Styrofoam cups. e. Make ice pops using the childs favorite juice. ANS: A, B, C, E Play activities to encourage fluid intake for a child include tea parties, crazy straws, cutting gelatin into fun shapes, and making ice pops using the childs favorite juice. Small cups, not large Styrofoam cups, should be used. Chapter 23.The Child with Fluid and Electrolyte Imbalance MULTIPLE CHOICE 1. What substance is released from the posterior pituitary gland and promotes water retention in the renal system? a. Renin b. Aldosterone c. Angiotensin d. Antidiuretic hormone (ADH) ANS: D ADH is released inornesep to i ncreased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the epaebrmility of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with sampala globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone. DIF: Cognitive Level: Understanding REF: MCS: 947 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. Nurses should be alert for rinecased f luid requirements in which circumstance? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative toufild vol ume. The mechanically ventilated childehcarseadsed f luid requirements. sCtoivnegheeart f luaire is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children. DIF: Cognitive Level: Understanding REF: MCS: 948 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3. What dfaiscptoorsepsre an infant to fluid imbalances? a. Decreased surface area b. Lower metabolic rate c. Immature kidney functioning d. Decreased daily exchange of extracellular fluid ANS: C The infants kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of uflid t o the environment. A higher metabolic rate is present as a result of the higher BSA in relation tovaectmi etabolic tissue. T he higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration. DIF: Cognitive Level: Understanding REF: MCS: 948 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4. What is the required number of milliliters of fluid needed per day for a 14-kg child? a. 800 b. 1000 c. 1200 d. 1400 ANS: C For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed. 10 kg 100 ml/kg/day = 1000 ml 4 kg 50 ml/kg/day = 200 ml 1000 ml + 200 ml = 1200 ml/day Eight hundred to 1000 ml is too little; 1400 ml is too much. DIF: Cognitive Level: Applying REF: MCS: 952 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation? a. Water excess b. Sodium excess c. Water depletion d. Potassium excess ANS: C These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms. DIF: Cognitive Level: Analyzing REF: MCS: 949 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. Clinical manifestations of sodium hexycpeesrsna(tremia) i nclude which soigr nssy mptoms? a. Hyperreflexia b. Abdominal cramps c. Cardiac dysrhythmias d. Dry, sticky mucous membranes ANS: D Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia. DIF: Cognitive Level: Understanding REF: MCS: 950 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. What laboratory finding should the nurse expect in a child with an excess of water? a. Decreased hematocrit b. High serum osmolality c. High urine specific gravity d. Increased blood urea nitrogen ANS: A The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reeavls decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the childs ability to correct the fluid imbalance. DIF: Cognitive Level: Understanding REF: MCS: 949 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)? a. Nausea, vomiting b. Weakness, fatigue c. Muscle hypotonicity d. Neuromuscular irritability ANS: D Neuromuscular irritability is a clinical manifestation ofcheympioac.aNl ausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia. DIF: Cognitive Level: Understanding REF: MCS: 951 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. What type of dehydration occurs welheecntrtohleyte deficit ex ceeds the water deficit? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. Hyperosmotic dehydration ANS: B Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Hyperosmotic dehydration is hanerotterm for hypertonic dehydration. DIF: Cognitive Level: Understanding REF: MCS: 952 TOP: NursoicnegssP:rAssessm ent MSC: Client Needs: Physiological Integrity 10. What amount of fluid loss occurs with moderate dehydration? a. <50 ml/kg b. 50 to 90 ml/kg c. <5% total body weight d. >15% total body weight ANS: B Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration. DIF: Cognitive Level: Understanding REF: MCS: 952 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 11. Physiologically, the child compensates for fluid volume losses by which mechanism? a. Inhibition of aldosterone secretion b. Hemoconcentration to reduce cardiac workload c. Fluid shift from interstitial space to intravascular space d. Vasodilation of peripheral arterioles to increase perfusion ANS: C Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure. DIF: Cognitive Level: Understanding REF: MCS: 952 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. Ongoing fluid losses can overwhelm the childs ability to compensate, resulting in shock. What early clinical sign precedes shock? a. Tachycardia b. Slow respirations c. Warm, flushed skin d. Decreased blood pressure ANS: A Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse. DIF: Cognitive Level: Understanding REF: MCS: 952 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant? a. Weight loss and decreased heart rate b. Capillary refill of less than 2 seconds and no tears c. Increased skin elasticity and sunken anterior fontanel d. Dry mucous membranes and generally ill appearance ANS: D A good predictor of a fluid idceift of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed. DIF: Cognitive Level: Applying REF: MCS: 957 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 14. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication? a. Oliguria b. Weight loss c. Irritability and seizures d. Muscle weakness and cardiac dysrhythmias ANS: C Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the mchpiltds taottme inatain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication. DIF: Cognitive Level: Understanding REF: MCS: 985 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 15. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic and respiratory acidosis d. Metabolic and respiratory alkalosis ANS: D The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Acidosis (both metabolic and respiratory) ihnaiscacll si gns of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis. DIF: Cognitive Level: Analysis REF: MCS: 962 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 16. What is an approximate method of estimating output for a child who is not toilet trained? a. Have parents estimate output. b. Weigh diapers after each void. c. Place a urine collection device on the child. d. Have the child sit on a potty chair 30 minutes after eating. ANS: B Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the childs skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating. DIF: Cognitive Level: Applying REF: MCS: 957 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 17. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins? a. Gently tap over the site. b. Apply a cold compress to the site. c. Raise the extremity above the level of the body. d. Use a rubber band as a tourniquet for 5 minutes. ANS: A Gently tapping the site can sometimes cause the veins to be more visible. This is done before the skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst when punctured. Five minutes is too long. DIF: Cognitive Level: Applying REF: MCS: 961 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 18. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action? a. Change the insertion site every 24 hours. b. Check the insertion site frequently for signs of infiltration. c. Use a macrodropper to facilitate reaching the prescribed flow rate. d. Avoid restraining the child to prevent undue emotional stress. ANS: B The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the asitnesrem ainct t (free of redness, edema, infiltration, or irritation), and the infusion does not stop. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the iclhd to s fiicgannit tra uma. A minidropper (60 drops/ml) is the recommended IV tubing in pediatric patients. Intravenous sites should be protected. This may require soft restraints on the child. DIF: Cognitive Level: Applying REF: MCS: 961 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19. The nurse determines that a childs intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action? a. Stop the infusion and apply ice. b. End the infusion and notify the practitioner. c. Slow the infusion rate and notify the practitioner. d. Discontinue the infusion and apply warm compresses. ANS: B A vesicant causes cellular damage when evennmutie amounts escape into the tissue. The intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is notified, and the treatment protocol is initiated. The applying of heat or ice depends on the fluid that has extravasated. The catheter is left in place until it is no longer needed. DIF: Cognitive Level: Applying REF: MCS: 972 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 20. Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)? a. You do not need to pierce the skin for access. b. It is easy to use for self-administered infusions. c. The patient does not need to limit regular physical activity, including swimming. d. The catheter cannot dislodge from the port even if the child plays with the port site. ANS: C No tliomnista on physical activity are needed. The child is able to ipcaiprtate in a ll regular physical activities, including bathing, showering, and swimming. The skin over the device is pierced with a Huber needle to access. Long-term central venous access devices are difficult to use for asedlmf-inistration. The port is placed under the skin. If the child manipulates the device and plays with the actual port, the catheter can be dislodged. DIF: Cognitive Level: Applying REF: MCS: 979 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 21. The nurse is teaching the family of a child with a long-term central nveous access device about signs and symptoms of bacteremia. What finding indicates the presence of bacteremia? a. Hypertension b. Pain at the entry site c. Fever and general malaise d. Redness and swelling at the entry site ANS: C Fever, chills, general malaise, and an ill appearance can be signs of bacteremia and require immediate intervention. Hypotension would be indicative of sepsis and possible impending cardiovascular collapse. Pain, redness, and swelling at the entry site indicate local infection. DIF: Cognitive Level: Applying REF: MCS: 979 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 2In2t.eWgrihtayt flush solution is recommended for intravenous catheters larger than 24 gauge? a. Saline b. Heparin c. Alteplase d. Heparin and saline combination ANS: A The recommended solution for flushing venous access devices is saline. The turbulent flow flush with saline is effective for ectaetrh s larger than 24.gTauge uhse of heparin does not increase the longevity of the venous access device. In 24-gauge catheters, rhienpma ay o ffer an advantage. Alteplase is used for treating catheter-related occlusions in children. The heparin and saline combination does not offer any advantage over saline or heparin individually. DIF: Cognitive Level: Applying REF: MCS: 977 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23. The nurse is teaching a parent of a 10-year-old child who will be discharged with a venous access device (VAD). What statement by the parent indicates a correct understanding of the teaching? a. I should have my child wear a protective vest when my child wants to participate in contact sports. b. I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. c. I can expect my child to have feelings of general malaise for 1 week after the VAD is inserted. d. I should give my child a sponge bath for the first 2 weeks after the VAD is inserted; then I can allow my child to take a bath. ANS: B The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. The child should not participate in contact sports, even with a protective vest, to prevent the VAD from becoming dislodged. General malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for any length of time. DIF: Cognitive Level: Analyzing REF: MCS: 979 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 24. What type of diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents? a. Osmotic b. Secretory c. Cytotoxic d. Dysenteric ANS: D Dysenteric diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms. Edema, mucosal bleeding, and leukocyte infiltration occur. Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is usually a result of ebraicatl enterotoxins that stimulate fluid and electrolyte secretion from the omsuacl crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the lvira destruction of the villi of the asmll intestine. T his results in alslemr intestinal surface a rea,twh i a decreased capacity for fluid and electrolyte absorption. DIF: Cognitive Level: Understanding REF: MCS: 952 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 25. What condition is often associated with severe diarrhea? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A Metabolic acidosis results from the increased absorption of shorta-icnhf atty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea. DIF: Cognitive Level: Understanding REF: MCS: 952 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Physiological Integrity 26. What organism is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli ANS: C G. lamblia is a parasite that represents 10% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens. DIF: Cognitive Level: Understanding REF: MCS: 948 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. A school-age child with diarrhea has been yredhrated. The nurse is discussing the childs diet with the family. What food or beverage should be tolerated best? a. Clear fluids b. Carbonated drinks c. Applesauce and milk d. Easily digested foods ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cows milk should be avoided in the recovery stage. DIF: Cognitive Level: Applying REF: MCS: 988 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological I2n8t.eAgristcyhool-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The childs mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention? a. Bring the child to the hospital for intravenous fluids. b. Alternate giving ORS and carbonated drinks. c. Continue to give ORS frequently in small amounts. d. Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided. ANS: C Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses. DIF: Cognitive Level: Implementation REF: MCS: 954 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 29. A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the childs diet be advanced to what kind of diet? a. Regular diet b. Clear liquids c. High carbohydrate diet d. BRAT (bananas, rice, applesauce, and toast or tea) diet ANS: A It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates. DIF: Cognitive Level: Implementation REF: MCS: 954 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 30. What is the most frequent cause of hypovolemic shock in children? a. Sepsis b. Blood loss c. Anaphylaxis d. Heart failure ANS: B Blood sloiss the most f erquent ecaoufs hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Heart failure contributes to hypervolemia, not hypovolemia. DIF: Cognitive Level: Understanding REF: MCS: 959 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 31. What type of shock is characterized by a hypersensitivitytrioeanc causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic shock b. Cardiogenic shock c. Hypovolemic shock d. Anaphylactic shock ANS: D Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission after a spinal cord idniojugreyn.iCc asrhock i s decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. DIF: Cognitive Level: Understanding REF: MCS: 959 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 32. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and ebsecdoemcompensated shoc k? a. Thirst b. Irritability c. Apprehension d. Confusion and somnolence ANS: D Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock. DIF: Cognitive Level: Understanding REF: MCS: 960 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 33. The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action? a. Place the child on a cardiac monitor. b. Obtain arterial blood gases. c. Provide supplemental oxygen. d. Put the child in the Trendelenburg position. ANS: C The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the childs status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head- down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume. DIF: Cognitive Level: Understanding REF: MCS: 961 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 34. What explains physiologically the edema formation that occurs with burns? a. Vasoconstriction b. Reduced capillary permeability c. Increased capillary permeability d. Diminished hydrostatic pressure within capillaries ANS: C With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure. DIF: Cognitive Level: Analyzing REF: MCS: 963 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 35. What is a systemic response to severe burns in a child? a. Metabolic alkalosis b. Decreased metabolic rate c. Increased renal plasma flow d. Abrupt drop in cardiac output ANS: D The initial physiologic response to a burn injury is a dramatic change in circulation. A precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes. A circulating myocardial depressant factor associated with severe burn injury is thought to be the cause. Metabolic acidosis usually occurs secondary to the disruption of the bodys buffering action oremsulting fr fluid shifting to extravascular space. There is a greatly accelerated metabolic rate in burn patients, supported by protein and lipid breakdown. With the loss of circulating volume, there is decreased renal blood flow and depressed glomerular filtration. DIF: Cognitive Level: Understanding REF: MCS: 975 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 36. A child is admitted with extensive burns. The nurse notes burns on the childs lips and singed nasal hairs. The nurse should suspect what condition in the child? a. A chemical burn b. A hot-water scald c. An electrical burn d. An inhalation injury ANS: D Evidence of an inhalation injury includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed for up to 24 hours. Chemical burns, electrical burns, and burns associated with hot-water scalds would not produce singed nasal hair. DIF: Cognitive Level: Analyzing REF: MCS: 993 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 37. What is the tmiomsmediate thr eat to life in children with thermal injuries? a. Shock b. Anemia c. Local infection d. Systemic sepsis ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication. DIF: Cognitive Level: Analyzing REF: MCS: 972 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 38. After the acute stage and during the healing process, what is the primary complication from burn injury? a. Shock b. Asphyxia c. Infection d. Renal shutdown ANS: C During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock. DIF: Cognitive Level: Analyzing REF: MCS: 975 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 39. What sign is one of the first to indicate overwhelming sepsis in a child with burn injuries? a. Seizures b. Bradycardia c. Disorientation d. Decreased blood pressure ANS: C Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis. DIF: Cognitive Level: Understanding REF: MCS: 976 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 40. A toddler sustains a minor burn on the hand from hot coffee. What is the first action in treating this burn? a. Apply burn ointment. b. Put ice on the burned area. c. Cover the hand with gauze dressing. d. Hold the hand under cool running water. ANS: D In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ointments are not applied to a new burn; the ointment will contribute to the burning. Ice is not recommended. Gauze dressings do not stop the burning process. DIF: Cognitive Level: Applying REF: MCS: 977 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 41. What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns? a. Absence of thirst b. Falling hematocrit c. Increased seepage from burn wound d. Urinary output of 1 to 2 ml/kg of body weight/hr ANS: D Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increasedasgeeepfrom a burn wound would be indicative of increased output, not adequate hydration. DIF: Cognitive Level: Applying REF: MCS: 978 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 42. What is the purpose of a high-protein diet for a child with major burns? a. Promote growth b. Improve appetite c. Minimize protein breakdown d. Diminish risk of stress-induced hyperglycemia ANS: C Initially after major burns, there is a hypometabolic phase, which lasts for 2 or 3 days. A hypermetabolic phase follows, characterized by increased body temperature, oxygen and glucose consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This response continues for up to 9 months. A diet high in protein and calories is necessary. Healing, not growth, is the primary consideration. Many children have poor appetites, and supplementation is necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted. DIF: Cognitive Level: Applying REF: MCS: 979 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 43. Fentanyl and midazolam (Versed) are given before dbridement of a childs burn wounds. What is the purpose of using these medications? a. Facilitate healing b. Provide pain relief c. Minimize risk of infection d. Decrease amount of dbridement needed ANS: B Partial-thickness burns require dbridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns. DIF: Cognitive Level: Analyzing REF: MCS: 980 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 44. Hydrotherapy is required to treat a lcdhiw is the purpose of hydrotherapy? a. Provide pain relief b. Dbride the wounds c. Destroy bacteria on the skin d. Increase peripheral blood flow ANS: B thie exnst ive partial-thickness burn wounds. What Soaking in a tub or showering once or twice a day acts to loosen and remove sloughing tissue, exudate, and topical medications. The hydrotherapy cleanses the wound and the entire body and helps maintain range of motion. Appropriate pain medications are necessary. Dressing changes are extremely painful. The total bacterial count of the skin is reduced by the hydrotherapy, but this is not the primary goal. There may be an increase in peripheral blood flow, but the primary purpose is for wound dbridement. DIF: Cognitive Level: Applying REF: MCS: 980 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 45. What is the nursing action related to the applying of biologic or synthetic skin coverings for a child with partial-thickness burns of both legs? a. Splint the legs to prevent movement. b. Observe wounds for signs of infection. c. Monitor closely for manifestations of shock. d. Examine dressings for indications of bleeding. ANS: B When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biologic dressings are used. DIF: Cognitive Level: Applying REF: MCS: 982 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 46. What is an effective strategy to reduce the stress of burn dressing procedures? a. Involve the child and give choices as feasible. b. Explain to the child why analgesics cannot be used. c. Reassure the child that dressing changes are not painful. d. Encourage the child to master stress with controlled passivity. ANS: A Children who have an understanding of the procedure and some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. Analgesia and sedation can and should be used. The dressing change procedure is very painful and stressful. Misinformation should not be given to the child. Encouraging the child to master stress with controlled passivity is not a positive coping strategy. DIF: Cognitive Level: Applying REF: MCS: 988 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 47. What consideration is important for the nurse when changing dressings and applying topical medication to a childs abdomen and leg burns? a. Apply topical medication with clean hands. b. Wash hands and forearms before and after dressing change. c. If dressings have adhered to the wound, soak in hot water before removal. d. Apply dressing so that movement is limited during the healing process. ANS: B Frequent hand and forearm washing is the single most important element of the infection-control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion. DIF: Cognitive Level: Analyzing REF: MCS: 988 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 48. What is a strategy used to minimize scarring with burn injury in a child? a. Applying of drying agents on skin b. Use of loose-fitting garments over healing areas c. Limitation of period without pressure to areas of scarring d. Immobilization of extremities while healing is occurring ANS: C Uniform pressure to the scar decreases the blood supply and forces the collagen into a more normal alignment. When pressure is removed, blood supply to the scar is immediately increased; therefore, periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Moisturizing agents are used with massage to help stretch tissue and prevent contractures. Compression garments, not loose-fitting garments, are indicated. Range of motion exercises are done to minimize contractures. DIF: Cognitive Level: Analyzing REF: MCS: 989 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 49. Prevention of burn injury is important anticipatory guidance. In the infant and toddler period, which mode is the most common cause of burn? a. Matches b. Electrical cords c. Hot liquids in the kitchen d. Microwave-heated foods ANS: C Infants and toddlers are most commonly injured by hot liquids in the kitchen and bathroom. This often occurs as a result of inadequate supervision of this curious and energetic age group. Matches and lighters are seen as toys by young children and should be kept out of reach. Older toddlers and preschool children are at risk of chewing on electrical cords and placing objects in outlets. Microwave-heated fluids and foods can become superheated, resulting in oral burns. DIF: Cognitive Level: Analyzing REF: MCS: 992 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 50. The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant icnadtes a need f or iaodndailt t eaching? a. I can alternate using a tampon and a sanitary napkin. b. I should wash my hands before inserting a tampon. c. I can use a superabsorbent tampon for more than 6 hours. d. I should call my health care provider if I suddenly develop a rash that looks like sunburn. ANS: C Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears. DIF: Cognitive Level: Applying REF: MCS: 958 TOP: Integrated Process: Teaching/ Learning MSC: Client Needs: Physiological 5In1t.eTgrhietynurse is caring for an 18-month-old child with rotavirus. What clinical manifestations should the nurse expect to observe? a. Severe abdominal cramping and bloody diarrhea b. Mild fever and vomiting followed by onset of watery stools c. Colicky abdominal pain and vomiting d. High fever, diarrhea, and lethargy ANS: B Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen with Escherichia coli infection; colicky abdominal pain and vomiting are seen with salmonella infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella typhi. DIF: Cognitive Level: Applying REF: MCS: 954 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.) a. Tachypnea b. Oliguria c. Confusion d. Pale extremities e. Hypotension f. Thready pulse ANS: A, B, C, D As shock progresses, perfusion inethmicrocirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor lcaarpyilf illing. Hypotension and a thready pulse are clinical manifestations of irreversible shock. DIF: Cognitive Level: Applying REF: MCS: 960 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.) a. Oliguric renal failure b. Increased intracranial pressure c. Mechanical ventilation d. Compensated hypotension e. Tetralogy of Fallot f. Type 1 diabetes mellitus ANS: A, B, C The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical vileantiton can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements. DIF: Cognitive Level: Applying REF: MCS: 946 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 3. What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.) a. Thick, doughy feel to the skin b. Slightly moist mucous membranes c. Absent tears d. Very rapid pulse e. Hyperirritability ANS: B, C, D Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration. DIF: Cognitive Level: Applying REF: MCS: 952 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.) a. Twitching b. Hypotension c. Hyperreflexia d. Muscle weakness e. Cardiac arrhythmias ANS: B, D, E Signs and symptoms of hypokalemia are hypotension, muscle weakness,aacnd cardi arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia. DIF: Cognitive Level: Applying REF: MCS: 950 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 5. The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which signs and symptoms of hypercalcemia? (Select all that apply.) a. Tetany b. Anorexia c. Constipation d. Laryngospasm e. Muscle hypotonicity ANS: B, C, E Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity. Tetany and laryngospasm are signs of hypocalcemia. DIF: Cognitive Level: Applying REF: MCS: 951 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 6. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.) a. Apathy b. Lethargy c. Oliguria d. Intense thirst e. Dry, sticky mucos ANS: B, C, E Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucos. Apathy and lethargy are signs of hyponatremia. DIF: Cognitive Level: Applying REF: MCS: 950 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity COMPLETION 1. A health care provider prescribes dopamine (Intropin), 5 mcg/kg/min in a continuous intravenous (IV) infusion for a child in shock. The child weighs 25 kg. The medication is available as dopamine 400 mg in 250 ml. The nurse prepares to calculate the rate. How many milliliters per hour will the nurse set the IV infusion pump to deliver 5 mcg/kg/min? Fill in the blank. Round to one decimal place. ANS: 4.7 Follow the formula for dosage calculation. 5 kg 60 = Pump rate ml/hr Drug concentration The patient weighs 10 kg, and the drug is available as 400 mg in 250 ml. Calculate the drug concentration. 400 1000 = 1600 mcg/ml 250 Then calculate the infusion rate. 5 25 60 = 4.6875 ml/hr = rounded to 4.7 ml/hr 1600 DIF: Cognitive Level: Applying REF: MCS: 962 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2. A health care provider prescribes diphenhydramine (Benadryl), 1 mg/kg PO every 4 to 6 hours as needed for pruritus to a child with a mild cutaneous anaphylactic reaction. The child weighs 5 kg. The medication label states: Diphenhydramine 12.5 mg/5 ml. The nurse prepares to administer one dose. How many milliliters will the enuprrs the blank. Record your answer in a whole number. epare to administer one dose? Fill in ANS: 2 Follow the formula for dosage calculation. Multiply 1 mg 5 kg to get the dose = 5 mg Desired Volume = ml per dose Available 5 mg 5 mL = 2 mL 12.5 mg DIF: Cognitive Level: Applying REF: MCS: 966 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 3. A health care provider prescribes nitroprusside (Nipride), 1 mcg/kg/min in a continuous intravenous (IV) infusion for a child in shock. The child weighs 20 kg. The medication is available as nitroprusside 50 mg in 250 ml. The nurse prepares to calculate the rate. How many milliliters per hour will the nurse set the iIoVninfus blank. Record your answer in a whole number. pump ltiovdere 1 m cg/kg/min? Fill in the ANS: 6 Follow the formula for dosage calculation. 1 kg 60 = Pump rate ml/hr Drug concentration The patient weighs 20 kg and the drug is available as 50 mg in 250 ml. Calculate the drug concentration. 50 1000 = 200 mcg/ml 250 Then calculate the infusion rate. 1 20 60 = 6 ml/hr 200 DIF: Cognitive Level: Applying REF: MCS: 964 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 4. A health care provider prescribes midazolam (Versed) syrup 0.5 mg/kg per mouth (PO) 30 minutes before a burn wound dressing change on a child. The medication label states: Versed 2 mg/1 ml. The child weighs 8 kg. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer the dose? Fill in the blank. Record your answer in a whole number. ANS. 2 Chapter 24.The Child with Renal Dysfunction MULTIPLE CHOICE 1. Urinary tract anomalies are frequently associated with what irregularities in fetal development? a. Myelomeningocele b. Cardiovascular anomalies c. Malformed or low-set ears d. Defects in lower extremities ANS: C Although unexplained, there is a frequent association between malformed or low-set ears and urinary tract anomalies. During the newborn examination, the nurse should have a high suspicion about urinary tract structure and function if ear anomalies are present. Children who have myelomeningocele may have impaired urinary tract function secondary to the neural defect. When other congenital defects are present, there is an increased likelihood of other issues with other body systems. Cardiac and extremity defects do not have a strong association with renal anomalies. DIF: Cognitive Level: Understanding REF: MCS: 1000 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 2. What urine test result isdecroendsa bnormal? a. pH 4.0 b. WBC 1 or 2 cells/ml c. Protein level absent d. Specific gravity 1.020 ANS: A The expected pH ranges from 4.8 to 7.8. A pH of 4.0 can be indicative of urinary tract infection or metabolic alkalosis or acidosis. Less than 1 or 2 white blood cells per milliliter is the expected range. The absence of protein is expected. The presence of protein can be indicative of glomerular disease. A specific gravity of 1.020 is within the anticipated range of 1.001 to 1.030. Specific gravity reflects level of hydration in addition to renal disorders and hormonal control such as antidiuretic hormone. DIF: Cognitive Level: Analyzing REF: MCS: 1002 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 3. What diagnostic test allows visualization of renal parenchyma and renal pelvis without exposure to external-beam radiation or aracdtiivoe isotopes? a. Renal ultrasonography b. Computed tomography c. Intravenous pyelography d. Voiding cystourethrography ANS: A The transmission of ultrasonic waves through the renal parenchyma allows visualization of the renal parenchyma and renal pelvis without exposure to external-beam aratidoin or radioactive isotopes. Computed tomography uses external radiation, and sometimes contrast media are used. Intravenous pyelography uses contrast medium and external radiation for radiography. Contrast medium is injected into the bladder through the urethral opening. External radiation for radiography is used before, during, and after voiding in voiding cystourethrography. DIF: Cognitive Level: Understanding REF: MCS: 1011 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. What name is given to inflammation of the bladder? a. Cystitis b. Urethritis c. Urosepsis d. Bacteriuria ANS: A Cystitis is an inflammation of the dbdlaer. U thrrietis is an inf lammation of the tuhrrea. U rosepsis is a febrile urinary tract infection with systemic signs of bacterial infection. Bacteriuria is the presence of bacteria in the urine. DIF: Cognitive Level: Understanding REF: MCS: 1004 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. The nurse is teaching a client to prevent future urinary tract infections (UTIs).tWf ha actor is most important toseimpha ze as the potential cause? a. Poor hygiene b. Constipation c. Urinary stasis d. Congenital anomalies ANS: C Urinary stias is the single most important host factor that einsfluenc the development of UTIs. Urine aislluyssu ritlee b ut at body temperature provides an excellent growth medium for bacteria. Poor hygiene can be a contributing cause, especially inafleems becaus e their short urethras predispose them to UTIs. Urinary stasis then provides a growth medium for the bacteria. Intermittent constipation contributes to urinary astsis. A f ull rectum displaces the bladder and posterior urethra in the fixed and limited space of the bony pelvis, causing obstruction, incomplete micturition, and urinary stasis. Congenital anomalies can contribute to UTIs, but urinary stasis is the primary factor in many cases. DIF: Cognitive Level: Applying REF: MCS: 1005 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 6. A girl, age 5 1/2 years, has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to her parent that the first action is to have the child evaluated for what condition? a. School phobia b. Glomerulonephritis c. Urinary tract infection (UTI) d. Attention deficit hyperactivity disorder (ADHD) ANS: C Girls between the ages of 2 and 6 years are considered high Irsis.kTfhoirs UT child is showing signs of a UTI, including incontinence in a toilet-trained child and possible urinary frequency or urgency. A physiologic cause should be ruled out before psychosocial factors are investigated. Glomerulonephritis usually manifests with rdeeacsed ur inary output and fluid retention. ADHD can contribute to urinariyniennccoenbt e cause the child tirsadcitsed, but the tfimrsanifestation was incontinence, not distractibility. DIF: Cognitive Level: Applying REF: MCS: 1008 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 7. What recommendation should the nurse make to prevent urinary tract infections (UTIs) in young girls? a. Avoid public toilet facilities. b. Limit long baths as much as possible. c. Cleanse the perineum with water after voiding. d. Ensure clear liquid intake of 2 L/day. ANS: D Adequate fluid intake minimizes urinary stasis. The recommended fluid intake is 50 ml/kg or 100 ml/lb per day. The average 5- to 6-year-old weighs approximately 18 kg (40 lb), so she should drink 2 L/day of fluid. There is no evidence that using public toilet facilities increases UTIs. Long baths are not associated with increased UTIs. Proper hand washing and perineal cleansing are important, but no evidence exists that these decrease UTIs in young girls. DIF: Cognitive Level: Applying REF: MCS: 1010 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 8. In teaching the parent of a newly diagnosed 2-year-old child with pyelonephritis related to vesicoureteral reflux (VUR), the nurse should include which information? a. Limit fluids to reduce reflux. b. Give cranberry juice twice a day. c. Have siblings examined for VUR. d. Surgery is indicated to reverse scarring. ANS: C Siblings are at high Rris. kTfhoer VU incidence of reflux in siblings is approximately 36%. The other children should be screened for early detection and to potentially reduce scarring. Fluids are not reduced. The efficacy of cranberry juice in reducing infection in children has not been established. Surgery may be necessary for higher grades of VUR, but the scarring is not reversible. DIF: Cognitive Level: Applying REF: MCS: 1010 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 9. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis? a. Infarction of renal vessels b. Immune complex formation and glomerular deposition c. Bacterial endotoxin deposition on and destruction of glomeruli d. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation ANS: B After a streptococcal infection, antibodies are formed, and immune-complex reaction occurs. The immune complexes are trapped in the glomerular capillary loop. Infarction of renal vessels occurs in renal involvement in sickle cell disease. Bacterial endotoxin deposition on and destruction of glomeruli is not a mechanism for postinfectious glomerulonephritis. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation is the pathology of renal involvement with bacterial endocarditis. DIF: Cognitive Level: Understanding REF: MCS: 1013 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likelyucsae of this weight loss? a. Poor appetite b. Reduction of edema c. Restriction to bed rest d. Increased potassium intake ANS: B This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 lb in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized. DIF: Cognitive Level: Understanding REF: MCS: 1014 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 11. What measure of fluid balance status is most useful in a child with acute glomerulonephritis? a. Proteinuria b. Daily weight c. Specific gravity d. Intake and output ANS: B A record of daily weight is the most useful smteoanasse ss fluid balance and should be kept for children treated at home or in the hospital. Proteinuria does not provide information about fluid balance. Specific gravity does not accurately reflect fluid balance in acute glomerulonephritis. If fluid is being retained, the excess fluid will not be included. Also proteinuria and hematuria affect specific gravity. Intake and output can be useful but are not dcoernesdi as accurate as daily weights. In children who are not toilet trained, measuring output is more difficult. DIF: Cognitive Level: Analyzing REF: MCS: 1015 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 12. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What knowledge should influence the nurses reply? a. The antibiotic therapy contributes to labile blood pressure values. b. Hypotension leading to sudden shock can develop at any time. c. Acute hypertension is a concern that requires monitoring. d. Blood pressure fluctuations indicate that the condition has become chronic. ANS: C Blood pressure monitoring is essential to identify acute hypertension, which is treated aggressively. Antibiotic therapy is usually not indicated for glomerulonephritis. Hypertension, not hypotension, is a concern in glomerulonephritis. Blood pressure control is essential to prevent further renal damage. Blood pressure fluctuations do not provide information about the chronicity of the disease. DIF: Cognitive Level: Applying REF: MCS: 1015 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 13. What laboratory finding, in conjunction with the presenting symptoms, indicates minimal change nephrotic syndrome? a. Low specific gravity b. Decreased hemoglobin c. Normal platelet count d. Reduced serum albumin ANS: D Total serum protein concentrations are reduced, with the albumin fractions significantly reduced. Specific gravity is high and proportionate to the amount of protein in the urine. Hemoglobin and hematocrit are usually norvaatledo.r ele hemoconcentration. The platelet count is elevated as a result of DIF: Cognitive Level: Analyzing REF: MCS: 1017 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Physiological Integrity 14. What is the primary objective of care for the child with minimal change nephrotic syndrome (MCNS)? a. Reduce blood pressure. b. Lower serum protein levels. c. Minimize excretion of urinary protein. d. Increase the ability of tissue to retain fluid. ANS: C The objectives of therapy for the child with MCNS include reducing the excretion of urinary protein, reducing fluid retention, preventing infection, and minimizing complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Serum protein levels are already reduced as part of the disease process.iTs hneeds to be reversed. eThtissue i s already retaining fluid as part of tehdeema. T he goal of therapy is to reduce edema. DIF: Cognitive Level: Understanding REF: MCS: 1017 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 15. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. What nursing goal is appropriate for this child? a. Stimulate appetite. b. Detect evidence of edema. c. Minimize risk of infection. d. Promote adherence to the antibiotic regimen. ANS: C High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis. DIF: Cognitive Level: Analyzing REF: MCS: 1019 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 16. The nurse is teaching a child experiencing severe edema associated with minimal change nephrotic syndrome about his diet. The nurse should discuss what dietary need? a. Consuming a regular diet b. Increasing protein c. Restricting fluids d. Decreasing calories ANS: C During the edematous stage of active nephrosis, lthdehcahsirestricted fluid and sodium intake. As the edema subsides, the child is placed on a diet with increased salt and fluids. A regular diet is not indicated. There is no evidence that a diet high in protein is beneficial or has an effect on the course of the disease. Calories sufficient for grsoswutehhaenadlintig are essential. With the child having little appetite and the ifdlua difficult. ltnrde starictio ns, achieving adequate nutrition is DIF: Cognitive Level: Applying REF: MCS: 1019 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 17. A child is admitted for minimal change nephrotic syndrome (MCNS). The nurse recognizes that the childs prognosis is related to what factor? a. Admission blood pressure b. Creatinine clearance c. Amount of protein in urine d. Response to steroid therapy ANS: D Corticosteroids are the drugs of choice for MCNS. If the child has not responded to therapy within 28 days of daily steroid administration, the likelihood of subsequent response decreases. Blood pressure is normal or low in MCNS. It is not correlated with opsroisg.nC atrineine clearance is not correlated with prognosis. The presence of significant proteinuria is used for diagnosis. It is not predictive of prognosis. DIF: Cognitive Level: Analyzing REF: MCS: 1019 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 18. A 12-year-old child is injured in a bicycle accident. When considering the possibility of renal trauma, the nurse should consider what factor? a. Flank pain rarely occurs in children with renal injuries. b. Few nonpenetrating injuries cause renal trauma in children. c. Kidneys are immobile, well protected, and rarely injured in children. d. The amount of hematuria is not a reliable indicator of the seriousness of renal injury. ANS: D Hematuria is consistently present with renal trauma. It does not provide a reliable indicator of the seriousness of the renal injury. Flank pain results from bleeding around the kidney. Most injuries that cause renal trauma in children are of the nonpenetrating or blunt type and usually involve falls, athletic injuries, and motor vehicle accidents. In children, the kidneys are more mobile, and the outer borders are less protected than in adults. DIF: Cognitive Level: Applying REF: MCS: 1018 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 19. What condition is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Severe dehydration d. Upper tract obstruction ANS: C The most common cause of acute renal failure in children eishdydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause. DIF: Cognitive Level: Understanding REF: MCS: 1022 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Physiological Integrity 20. A child is admitted in acute renal failure (ARF). Therapeutic management to rapidly provoke a flow of urine includes the administration of what medication? a. Propranolol (Inderal) b. Calcium gluconate c. Mannitol (Osmitrol) or furosemide (Lasix) (or both) d. Sodium, chloride, and potassium ANS: C In ARF, if hydration is adequate, mannitol or furosemide (or both) is administered to provoke a flow of urine. If glomerular function is cint,taan os motic diuresis will occur. Propranolol is a beta-blocker; it will not produce a rapid flow of urine in ARF. Calcium gluconate is administered for sitprotective cardi ac effect when hyperkalemia exists. It does not affect diuresis. Electrolyte measurements must be done before administration of sodium, chloride, or potassium. These substances are not given unless there are other large, ongoing losses. In the absence of urine production, potassium levels may be elevated, and additional potassium can cause cardiac dysrhythmias. DIF: Cognitive Level: Analyzing REF: MCS: 1027 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 21. What major complication is associated with ladcwhi thic hronic renal failure? a. Hypokalemia b. Metabolic alkalosis c. Water and sodium retention d. Excessive excretion of blood urea nitrogen ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. eHrykpalemia, m etabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure. DIF: Cognitive Level: Analyzing REF: MCS: 1030 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. What diet is most appropriate for the child with chronic renal failure (CRF)? a. Low in protein b. Low in vitamin D c. Low in phosphorus d. Supplemented with vitamins A, E, and K ANS: C Dietary phosphorus may need to be restricted by limiting protein and milk intake. Substances that bind phosphorus are given with emveeanlts to pr its absorption, which enables a more liberal intake of phosphorus-containing protein. Protein is limited to the oremcmended da ily allowance for the childs age. Further restriction is thought to negatively affect growth and neurodevelopment. VitaminpDy thera is administered in children with CRF to increase calcium absorption. Supplementation of vitamins A, E, and K, beyond normal dietary intake, is not advised in children with CRF. These fat-soluble vitamins can accumulate. DIF: Cognitive Level: Analyzing REF: MCS: 1030 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23. What nursing consideration is most important when caring for a child with end-stage renal disease (ESRD)? a. Children with ESRD usually adapt well to minor inconveniences of treatment. b. Children with ESRD require extensive support until they outgrow the condition. c. Multiple stresses are placed on children with ESRD and their families until the illness is cured. d. Multiple stresses are placed on children with ESRD and their families because childrens lives are maintained by drugs and artificial means. ANS: D Stressors on the family are often overwhelming because of the progressive deterioration. The child progresses from renal insufficiency to uremia to dialysis and transplantation, each of which requires intensive therapy and isvueppcoaret . T he treatment of ESRD is intense and requires multiple examinations, dietary restrictions, and medications. Adherence to the regimen is often difficult for children and families because of the progressive nature of the renal failure. ESRD has an unrelenting course that has no known cure. Children do not outgrow the renal failure. DIF: Cognitive Level: Analyzing REF: MCS: 1033 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 24. The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause? a. Physiologic manifestations of renal disease b. The fact that adolescents have few coping mechanisms c. Neurologic manifestations that occur with dialysis d. Resentment of the control and enforced dependence imposed by dialysis ANS: D Older children and adolescents need to feel inrcool.nDt ialysis forces the adolescent into a dependent relationship, which results in these behaviors. Being angry, hostile, or depressed are functions of the age of the child, not neurologic or physiologic manifestations of the dialysis. DIF: Cognitive Level: Analyzing REF: MCS: 1037 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Psychosocial Integrity 25. What statement is an advantage of peritoneal dialysis compared with hemodialysis? a. Protein loss is less extensive. b. Dietary limitations are not necessary. c. It is easy to learn and safe to perform. d. It is needed less frequently than hemodialysis. ANS: C Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Protein loss is not significantly different. The dietary limitations are necessary, but theyearnot as stringent as those for ohdemialysis. Treatments are needed meqoureenftrly but ca n be done at home. DIF: Cognitive Level: Analyzing REF: MCS: 1036 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 26. What statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. Children can receive kidneys only from other children. c. It is the preferred means of renal replacement therapy in children. d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible. ANS: C Renal transplantation offers the opportunity for a relatively normal life and is the preferred means of renal replacement therapy inteangde-rsenal disease. It can b e done in children as young as age 6 months. Both children and adults can serve as donors for lretna ransplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis. DIF: Cognitive Level: Understanding REF: MCS: 1038 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. The nurse is conducting discharge teaching with the parent of a 7-year-old child with minimal change nephrotic syndrome (MCNS). What statement by the parent indicates a correct understanding of the teaching? a. My child needs to stay home from school for at least 1 more month. b. I should not add additional salt to any of my childs meals. c. My child will not be able to participate in contact sports while receiving corticosteroid therapy. d. I should measure my childs urine after each void and report the 24-hour amount to the health care provider. ANS: B Children with MCNS cnabe teredaat home a fter the initial phase with oaprirate d ischarge instructions, including a salt restriction of no additional salt to the lcdhsi meals. The child may return to school but should avoid exposure to infected playmates. Participation in contact sports is not affected by corticosteroid therapy. The parent does not need to measure the childs urine on a daily basis but may be instructed to test for albumin. DIF: Cognitive Level: Applying REF: MCS: 1019 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 28. What is the narrowing of preputial opening of foreskin called? a. Chordee b. Phimosis c. Epispadias d. Hypospadias ANS: B Phimosis is the narrowing or stenosis of the preputial opening eosfktihne. fCohrordee is the ventral curvature of the penis. Epispadias is the meatal opening on tdhoersal su rface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. DIF: Cognitive Level: Understanding REF: MCS: 1040 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 29. Identification and treatment of cryptorchid testes should be done by age 2 years. What is an important consideration? a. Medical therapy is not effective after this age. b. Treatment is necessary to maintain the ability to be fertile when older. c. The younger child can tolerate the extensive surgery needed. d. Sexual reassignment may be necessary if treatment is not successful. ANS: B The longer the testis is exposed to higher body heat, the greater the likelihood of damage. To preserve fertility, surgery should be done at an early age. Surgical intervention is the treatment of choice. Simple orchiopexy is usually performed as an outpatient procedure. The surgical procedure restores the testes to the scrotum. This helps the boy to have both testes in the scrotum by school age. Sexual reassignment is not indicated when the testes are not descended. DIF: Cognitive Level: Understanding REF: MCS: 1041 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 30. Congenital defects of the genitourinary tract, such as hypospadias, are usually repaired as early as possible to accomplish what? a. Minimize separation anxiety. b. Prevent urinary complications. c. Increase acceptance of hospitalization. d. Promote development of normal body image. ANS: D Promoting development of normal body image is extremely important. Surgery involving sexual organs can be upsetting to children, especially preschoolers, who fear mutilation and castration. Proper preprocedure preparation can facilitate coping with these issues. Preventing urinary complications is important for defects that affect function, but for all external defects, repair should be done as soon as possible. DIF: Cognitive Level: Analyzing REF: MCS: 1043 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Itengrity 31. The parents of a 2-year-old boy who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son. The nurse replies based on what knowledge? a. Most boys in the United States can be toilet trained at age 3 years. b. Training can begin when he has sufficient bladder capacity. c. Additional surgery may be necessary to achieve continence. d. They should begin now because he will require additional time. ANS: C After repair of the bladder exstrophy, the childs bladder is allowed to increase capacity. Several surgical procedures may be necessary to create a urethral sphincter mechanism to aid in urination and ejaculation. With the lack of a urinary sphincter, toilet training is unlikely. The child cannot hold the urine in the bladder. Bladder capacity is one component of continence. A functional sphincter is also needed. DIF: Cognitive Level: Applying REF: MCS: 1045 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 32. An infant has been diagnosed with bladder obstruction. What do symptoms of this disorder include? a. Renal colic b. Strong urinary stream c. Urinary tract infections d. Posturination dribbling ANS: D Symptoms of bladder obstruction include poor force of urinary stream, intermittency of voided stream, feelings of incomplete bladder emptying, and posturination dribbling. They may also include urinary frequency, nocturia, nocturnal enuresis, and urgency. Renal colic is a symptom of upper urinary tract obstruction. Children with bladder obstruction have a weak urinary stream. Urinary tract infections are not associated with bladder obstruction. DIF: Cognitive Level: Applying REF: MCS: 1006 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 33. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurses intervention include? a. Explain the disorder so they can explain it to others. b. Help parents understand that this is a minor problem. c. Suggest that parents avoid family and friends until the gender is assigned. d. Encourage parents not to worry while the tests are being done. ANS: A Explaining the disorder to parents so they caainn ietxtpl o others is the most therapeutic approach while the parents await the gender assignment of their child. Ambiguous genitalia is a serious issue for tfhaemily. Careful itensgt and evaluation are necessary to aid inrgende assignment to avoid lifelong problems for the child. Suggesting that parents avoid family and friends until the gendersiisgansed is impractica l dand woul isolate the mfaily f rom their support system while awaiting stet r esults. The parents will be concerned. Telling them not to worry without giving them specific alternative actions would not be effective. DIF: Cognitive Level: Applying REF: MCS: 1043 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 34. Parents of a newborn with ambiguous genitalia want to know how long they will have to wait to know whether they have a boy or a girl. The nurse answers the parents based on what knowledge? a. Chromosome analysis will be complete in 7 days. b. A physical examination will be able to provide a definitive answer. c. Additional laboratory testing is necessary to assign the correct gender. d. Gender assignment involves collaboration between the parents and a multidisciplinary team. ANS: D Gender assignment is a complex decision-making process. Endocrine, genetic, social, psychologic, and ethical elements of sex assignment have been integrated into the process. Parent participation is included. The goal is to enable the affected child to grow into a well- adjusted, psychosocially stable person. Chromosome analysis usually takes 2 or 3 days. A physical examination reveals ambiguous genitalia, but additional testing is necessary. A correct gender may not be identifiable. DIF: Cognitive Level: Analyzing REF: MCS: 1043 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 35. Surgery is performed on a child to correct cryptorchidism. The parents understand the reason for the surgery if they tell the nurse this was done to do what? a. Prevent damage to the undescended testicle. b. Prevent urinary tract infections. c. Prevent prostate cancer. d. Prevent an inguinal hernia. ANS: A If the testes do not descend spontaneously, orchiopexy is performed before the childs second birthday, preferably between 1 and 2 years of age. Surgaiircaisl rdeopne to ( )1prevent da mage to the undescended testicle by exposure to the higher degree of body heat in the undescended location, thus maintaining future fertility; (2) decrease the incidence of malignancy formation, which is higher incuennddeesd testicles; ( 3) avoid trauma and torsion; (4) close the processus vaginalis; and (5) prevent the cosmetic and psychologic disability of an empty scrotum. Parents understand the teaching if they respond the surgery is done to prevent damage. DIF: Cognitive Level: Analyzing REF: MCS: 1041 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 36. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema? a. Place an ice pack on the scrotal area. b. Place the child in an upright sitting position. c. Elevate the scrotum with a rolled washcloth. d. Place a warm moist pack to the scrotal area. ANS: C In children hospitalized with MCNS,vealteing edematous parts may be helpful to shift fluid to more comfortable distributions.eAasr that are particularly ed ematous, such as the scrotum, abdomen, and legs, may require support. The scrotum can be elevated with a rolled washcloth. Ice or heat should not be used. Sitting the child in an upright position will not decrease the scrotal edema. DIF: Cognitive Level: Applying REF: MCS: 1017 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 37. What do tchleinical manifestations of minimal change nephrotic syndrome include? a. Hematuria, bacteriuria, and weight gain b. Gross hematuria, albuminuria, and fever c. Hypertension, weight loss, and proteinuria d. Massive proteinuria, hypoalbuminemia, and edema ANS: D Massive proteinuria, hypoalbuminemia, and edema are clinical manifestations of minimal change nephrotic syndrome. Hematuria and bacteriuria are not seen, and there is usually weight loss, not gain. The blood pressure is normal or hypotensive. DIF: Cognitive Level: Understanding REF: MCS: 1017 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 38. For minimal change nephrotic syndrome (MCNS), prednisone is effective when what occurs? a. Appetite increases and blood pressure is normal b. Urinary tract infection is gone and edema subsides c. Generalized edema subsides and blood pressure is normal d. Diuresis occurs as urinary protein excretion diminishes ANS: D Studies suggest that the duration of steroid treatment for the initial episode should be atstle3 months. In most patients, diuresis occurs as the urinary protein excretion diminishes within 7 to 21 days after the initiation of steroid therapy. The blood pressure is normal with MCNS, so remaining so is not an improvement. There is no urinary tract infection with MCNS. DIF: Cognitive Level: Understanding REF: MCS: 1017 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 39. A nurse is evaluating tehfefectiveness of teaching regarding care of a child with minimal change nephrotic syndrome (MNSC) tha t is in remission after administration of prednisone. The nurse realizes further teaching is required if the parents state what? a. We will keep our child away from anyone who is ill. b. We will be sure to administer the prednisone as ordered. c. We will encourage our child to eat a balanced diet, but we will watch his salt intake. d. We understand our child will not be able to attend school, so we will arrange for home schooling. ANS: D The child with MCNS in remission can attend school. The child needs socialization and will be socially isolated if home schooled. The other statements are accurate for home care for a child with MCNS. DIF: Cognitive Level: Applying REF: MCS: 1020 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 40. A parent asks the nurse what would be the first indication that acute glomerulonephritis was improving. What would be the nurses best response? a. Blood pressure will stabilize. b. Your child will have more energy. c. Urine will be free of protein. d. Urine output will increase. ANS: D The first sign of improvement in acute glomerulonephritis is an increase in urinary output with a corresponding decrease in body weight. With diuresis, the child begins to feel better, the appetite improves, and the blood pressure decreases to normal with the reduction of edema. Gross hematuria diminishes, in part because of dilution of the red blood cells in the more dilute urine. Renal function and hypocomplementemia usually normalize by 8 weeks. DIF: Cognitive Level: Applying REF: MCS: 1012 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 41. A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show? a. Bacteriuria and hematuria b. Hematuria and proteinuria c. Bacteriuria and increased specific gravity d. Proteinuria and decreased specific gravity ANS: B Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity. Proteinuria generally parallels the hematuria but tisunsuoally the massive proteinuria seen in nephrotic syndrome. Gross discoloration of urine reflects its red blood cell and hemoglobin content. Microscopic examination of the sediment shows many red blood cells, leukocytes, epithelial cells, and granular and red blood cell casts. Bacteria are not seen, and urine culture results are negative. DIF: Cognitive Level: Analyzing REF: MCS: 1012 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 42. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take? a. Check the urine to see if hematuria has increased. b. Obtain the childs blood pressure and notify the health care provider. c. Obtain serum electrolytes and send urinalysis to the laboratory. d. Reassure the child and encourage bed rest until the headache improves. ANS: B The premonitory signs of encephalopathy are headache, dizziness, abdominal discomfort, and vomiting. If the condition progresses, there may be transient loss of vision or hemiparesis, disorientation, and generalized tonic-clonic seizures. The health care provider shouldibfieednot of these symptoms. DIF: Cognitive Level: Applying REF: MCS: 1014 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 43. The nurse is preparing to admit a child to the hospital with a diagnosis of acute poststreptococcal glomerulonephritis. The nurse understands that the peak age at onset for this disease is what? a. 2 to 4 years b. 5 to 7 years c. 8 to 10 years d. 11 to 13 years ANS: B The peak age at onset for acute poststreptococcal glomerulonephritis is 5 to 7 years of age. DIF: Cognitive Level: Understanding REF: MCS: 1013 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 44. The nurse is preparing to admit a child to the hospital with a diagnosis of minimal change nephrotic syndrome. The nurse understands that the peak age at onset for this disease is what? a. 2 to 3 years b. 4 to 5 years c. 6 to 7 years d. 8 to 9 years ANS: A The peak age at onset for minimal change nephrotic syndrome is 2 to 3 years of age. DIF: Cognitive Level: Understanding REF: MCS: 1017 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity MULTIPLE RESPONSE 1. The enuisrsa dmitting a a9r-ye -old cldhiw thih meolytic ur emic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Hematuria b. Anorexia c. Hypertension d. Purpura e. Proteinuria f. Periorbital edema ANS: B, C, D Clinical manifestations of hemolytic uremic syndrome include anorexia; hypertension; and purpura, which persists for several days to 2 weeks. Gross hematuria is seen in acute glomerulonephritis. Substantial proteinuria and periorbital edema are common manifestations in nephrotic syndrome. DIF: Cognitive Level: Applying REF: MCS: 1023 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 2. The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin (Garamycin). What interventions ushldo the medication? (Select all that apply.) a. Encourage fluids. b. Monitor urinary output. c. Monitor sodium serum levels. d. Monitor potassium serum levels. e. Monitor serum peak and trough levels. ANS: A, B, E enuprls an ftohris c hild with regard to this Garamycin can cause renal toxicity and ototoxicity. Fluids should be encouraged and urinary output and serum peak and trough levels monitored. It is not necessary to monitor potassium sodium levels for patients taking this medication. DIF: Cognitive Level: Applying REF: MCS: 1007 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 3. The nurse is caring for a child with a urinary tract infection who is on trimethoprimsulfamethoxazole (Bactrim). What side effects of this medication should the nurse teach to the parents and the child? (Select all that apply.) a. Rash b. Urticaria c. Pneumonitis d. Renal toxicity e. Photosensitivity ANS: A, B, E Side effects of Bactrim are hra,s are not side effects of Bactrim. urticarioas,eannsditipvhitoyt. Pneumonitis and renal ittoyxic DIF: Cognitive Level: Applying REF: MCS: 1007 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.) a. Hyponatremia b. Hyperkalemia c. Metabolic alkalosis d. Elevated blood urea nitrogen level e. Decreased plasma creatinine level ANS: A, B, D A child with acute renal failure would have hyponatremia, hyperkalemia, and elevated blood urea nitrogen levels. The child would have metabolic acidosis, not alkalosis, and the plasma creatinine levels would be increased, not decreased. DIF: Cognitive Level: Analyzing REF: MCS: 1025 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 5. What signs and symptoms are indicative of a urinary tract disorder in the neonatal period (birth to 1 month)? (Select all that apply.) a. Edema b. Bradypnea c. Frequent urination d. Poor urinary stream e. Failure to gain weight ANS: C, D, E Signs and symptoms of a urinary otrradcetrdiis n the neonatal period are frequent urination, poor urinary stream, and failure to gain weight. The respirations would be rapid, not slow, and dehydration, not edema, occurs. DIF: Cognitive Level: Analyzing REF: MCS: 1001 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 6. What signs and symptoms are indicative of a urinary tract disorder in the infancy period (124 months)? (Select all that apply.) a. Pallor b. Poor feeding c. Hypothermia d. Excessive thirst e. Frequent urination ANS: A, B, D, E Signs and symptoms of a urinary otrradcetrdiis n the infancy period are pallor, poor feeding, excessive thirst, and frequent urination. Hyperthermia is seen, not hypothermia. DIF: Cognitive Level: Analyzing REF: MCS: 1001 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. What signs and symptoms are indicative of a urinary tract disorder in the childhood period (2 to 14 years)? (Select all that apply.) a. Fatigue b. Dehydration c. Hypotension d. Growth failure e. Blood in the urine ANS: A, D, E Signs and symptoms of a urinary tract disorder in the childhood period are fatigue, growth failure, and blood in the urine. Edema is noted, not dehydration, and hypertension is present, not hypotension. DIF: Cognitive Level: Analyzing REF: MCS: 1001 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. What dietary instructions should the nurse give to parents of a child in the oliguria phase of acute glomerulonephritis with edema and hypertension? (Select all that apply.) a. High fat b. Low protein c. Encouragement of fluids d. Moderate sodium restriction e. Limit foods high in potassium ANS: D, E Dietary restrictions depend on the stage and severity of acute glomerulonephritis, especially the extent of edema. A regular diet is permitted in uncomplicated cases, but sodium intake is usually limited (no salt is added to foods). Moderate sodium restriction is usually instituted for children with hypertension or edema. Foods with substantial amounts of potassium are generally restricted during the period of oliguria. Protein restriction is reserved only fcohrildren w ith severe azotemia resulting from prolonged oliguria. A low-protein, high-fat diet with encouragement of fluids would not be recommended. DIF: Cognitive Level: Applying REF: MCS: 1015 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. What dietary instructions should the nurse give to parents of a child with minimal change nephrotic syndrome with massive edema? (Select all that apply.) a. Soft diet b. High protein c. Fluid restricted d. No salt added at the table e. Restriction of foods high in sodium ANS: D, E The child with minimal change nephrotic syndrome maintains a regular diet, not soft. However, salt is restricted during periods of massive edema and while the patient is on corticosteroid therapy; no salt is added at the table, and foods with very high salt content are excluded. Although a low-sodium diet will not remove edema, its rate of increase may be reduced. Water is seldom restricted. A diet generous in protein is logical, but there is no evidence that it is beneficial or alters the outcome of the disease. DIF: Cognitive Level: Applying REF: MCS: 1019 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. What dietary instructions should the nurse give to parents of a child undergoing chronic hemodialysis? (Select all that apply.) a. High protein b. Fluid restriction c. High phosphorus d. Sodium restriction e. Potassium restriction ANS: B, D, E Dietary limitations are necessary in patients undergoing chronic dialysis to avoid biochemical complications. Fluid and sodium are restricted to prevent fluid overload and its associated symptoms of hypertension, cerebral manifestations, and congestive heart failure. Potassium is restricted to prevent complications related to hyperkalemia; phosphorus restriction helps prevent parathyroid hyperactivity and its attendant risk of abnormal calcification in soft tissues. Adequate protein, not high intake, is necessary to maximize growth potential. Fluid limitations are determined by residual urinary output and the need to limit intradialytic weight gain. DIF: Cognitive Level: Applying REF: MCS: 1016 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 11. A child is hospitalized in acute renal failure and has a serum potassium greater than 7 mEq/L. What temporary measures that will produce a rapid but transient effect to reduce the potassium should the nurse expect to be prescribed? (Select all that apply.) a. Dialysis b. Calcium gluconate c. Sodium bicarbonate d. Glucose 50% and insulin e. Sodium polystyrene sulfonate (Kayexalate) ANS: B, C, D Several measures are available to reduce the serum potassium concentration, and the priority of implementation is usually based on the rapidity with which the measures are effective. Temporary measures that produce a rapid but transient effect are calcium gluconate, sodium bicarbonate, and glucose 50%, and insulin. Definitive but slower-acting measures are then implemented which include administration of a cation exchange resin such as sodium polystyrene sulfonate (Kayexalate), 1 g/kg, administered orally or rectally, and/or dialysis. DIF: Cognitive Level: Analyzing REF: MCS: 1028 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 12. Parents of a child who lwl ine ed ohdemialysis ask t he nurse, What are the advantages of a fistula over a graefrtnaolr aecxct give? (Select all that apply.) ess device for ohedmialysis? W hat response should the nurse a. It is ready to be used immediately. b. There are fewer complications with a fistula. c. There is less restriction of activity with a fistula. d. It produces dilation and thickening of the superficial vessels. e. The fistula does not require a needle insertion at each dialysis. ANS: B, C, D The creation of a subcutaneous (internal) arteriovenous fistula by anastomosing a segment of the radial artery and brachiocephalic vein produces dilation and thickening of the superficial vessels of the forearm to provide easy access for aretepde venipuncture. F ewer complications and less restriction of activity are observed with the use of a fistula. Both the fgtrand the tfuisla re quire needle insertion at each dialysis. The fistula cannot be used immediately. DIF: Cognitive Level: Applying REF: MCS: 1036 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 13. What are signs and symptoms of a possible kidney transplant rejection in a child? (Select all that apply.) a. Fever b. Hypotension c. Diminished urinary output d. Decreased serum creatinine e. Swelling and tenderness of graft area ANS: A, C, E The child with a kidney transplant who exhibits any of the following should be evaluated immediately for possible rejection: fever, diminished urinary output, and swelling and tenderness of graft area. Hypertension, not hypotension, and increased, not edaescerd, ser um creatinine are signs of rejection. DIF: Cognitive Level: Analyzing REF: MCS: 1039 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity COMPLETION 1. A health care provider prescribes furosemide (Lasix), 10 mg intravenously (IV) now, for a child with acute glomerulonephritis. The medication label states: Furosemide (Lasix) 20 mg/2 ml. The enuprrs paeres to a dminister the .dose How many milliliters will the enuprrs epare to administer the dose? Fill in the blank. Record your answer in a whole number. ANS: 1 Follow the formula for dosage calculation. Desired Volume = ml per dose Available 10 mg 2 ml = 2 ml 20 mg DIF: Cognitive Level: Applying REF: MCS: 1015 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2. Calculate the 24-hour maintenance fluid requirement for a child weighing 25 kg. Fill in the blank with ml/day. Record your answer in a whole number. ANS: 1600 Follow the mfour la f or daily fluid requirements for children. First 10 kg: 100 ml/kg/day 10 kg = 1000 ml/day Second 10 kg: 50 ml/kg/day 10 kg = 500 ml/day Each additional 1 kg: 20 ml/kg/day 5 kg = 100 ml/day Answer: 1600 ml/day DIF: Cognitive Level: Applying REF: MCS: 1010 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 3. Calculate the 24-hour maintenance fluid requirement for a child weighing 6 kg. Fill in the blank with ml/day. Record your answer in a whole number. ANS: 600 Follow the mfour la f or daily dflurei quirements f or children. First 10 kg: 100 ml/kg/day 6 kg = 600 ml/day Answer: 600 ml Chapter 25.The Child with Gastrointestinal Dysfunction MULTIPLE CHOICE 1. What test is used to screen for carbohydrate malabsorption? a. Stool pH b. Urine ketones c. C urea breath test d. ELISA stool assay ANS: A The anticipated pH of a stool specimen is 7.0. A stool pH of less than 5.0 is indicative of carbohydrate malabsorption. The bacterial fermentation of carbohydrates in the colon produces short-chain fatty acids, which lower the stool pH. Urine ketones detect the presence of ketones in the urine, which indicates the use of alternative sources of energy to glucose. The C urea breath test measures the amount of carbon dioxide exhaled. It is used to determine the presence of Helicobacter pylori. ELISA (enzyme-linked immunosorbent assay) edcets the presence of antigens and antibodies. It is not useful for disorders of metabolism. DIF: Cognitive Level: Understanding REF: MCS: 1055 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 2. A toddlers mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurses response should be based on which premise? a. An emergency laparotomy is very likely. b. The location needs to be confirmed by radiographic examination. c. Surgery will be necessary if the battery has not passed in the stool in 48 hours. d. Careful observation is essential because an ingested battery cannot be accurately detected. ANS: B Button batteries can cause severe damage if lodged in the esophagus. If both poles of the battery come in contact with the wall of the esophagus, acid burns, necrosis, and perforation can occur. If the battery is in the stomach, it will most likely be passed without incident. Surgery is not indicated. The battery is metallic and is readily seen on radiologic examination. DIF: Cognitive Level: Applying REF: MCS: 1068 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 3. The mother of a child with icvoegnimitpairment scatlhle nurse because he r son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs? a. Gastrointestinal perforation may have occurred. b. The object may have been aspirated. c. The object may be lodged in the esophagus. d. The object may be embedded in stomach wall. ANS: C Gagging and drooling gmnasy be si of esophageal obstruction. The child is unable to swallow saliva, cwhhci ontributes to the ldirnogo. Signs of gastrointestinal (GI) perforation include scthe or abdominal pain and evidence of bleeding in the GI tract. If the object was aspirated, the child would most likely have coughing, choking, inability to speak, or difficulty breathing. If the object was embedded in the stomach wall, it would not result in symptoms of gagging and drooling. DIF: Cognitive Level: Applying REF: MCS: 1071 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 4. What is a high-fiber food that the nurse should recommend for a child with chronic constipation? a. White rice b. Popcorn c. Fruit juice d. Ripe bananas ANS: B Popcorn is a high-fiber food. Refined rice is not a significant source of fiber. Unrefined brown rice is a fiber source. Fruit juices are not a significant source of fiber. Raw ufrits, esp ecially those with skins and seeds, other than ripe bananas, have high fiber. DIF: Cognitive Level: Applying REF: MCS: 1074 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 5. A 2-year-old child has a chronic history of constipation and is brought to the clinic for evaluation. What should the therapeutic plan initially include? a. Bowel cleansing b. Dietary modification c. Structured toilet training d. Behavior modification ANS: A The first step in the treatment of chronic constipation is to empty the bowel and allow the distended rectum to rnetu to anlosrmize. D tariye modification is an important part of the treatment. Increased fiber and fluids should be gradually added to the childs diet. A 2-year-old child is too young for structured toilet training. For an older child, a regular schedule for toileting should be established. Behavior modification is part of the overall treatment plan. The child practices releasing the anal sphincter and recognizing cues for defecation. DIF: Cognitive Level: Understanding REF: MCS: 1072 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. What statement best describes Hirschsprung disease? a. The colon has an aganglionic segment. b. It results in frequent evacuation of solids, liquid, and gas. c. The neonate passes excessive amounts of meconium. d. It results in excessive peristaltic movements within the gastrointestinal tract. ANS: A Mechanical obstruction in the colon results from a lack of innervation. In most cases, the aganglionic segment includes the rectum and some portion of the distal colon. There is decreased evacuation of the large intestine secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon. DIF: Cognitive Level: Understanding REF: MCS: 1074 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. What procedure is most appropriate for assessment of an abdominal circumference related to a bowel obstruction? a. Measuring the abdomen after feedings b. Marking the point of measurement with a pen c. Measuring the circumference at the symphysis pubis d. Using a new tape measure with each assessment to ensure accuracy ANS: B Pen marks on either side of the tape measure allow the nurse to measure the same spot on the childs abdomen at each assessment. The child most likely will be kept NPO (nothing by mouth) if a bowel obstruction is present. If the child is being fed, the assessment should be done before feedings. The symphysis pubis is too low. Usually the largest part of the abdomen is at the umbilicus. Leaving the tape measure in place reduces the trauma to the child. DIF: Cognitive Level: Applying REF: MCS: 1067 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 8. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child? a. It is unnecessary because of childs age. b. It is essential because it will be an adjustment. c. Preparation is not needed because the colostomy is temporary. d. Preparation is important because the child needs to deal with negative body image. ANS: B The childs age dictates the type and extent of psychologic preparation. When a colostomy is performed, it is necessary to prepare the child who is at least preschool age by telling him or her about the procedure and what to expect in concrete terms, with the use of visual aids. The preschooler is not yet concerned with body image. DIF: Cognitive Level: Applying REF: MCS: 1075 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 9. A child has a nasogastric (NG) tube after surgery for rHsichsprung disease. What is the purpose of the NG tube? a. Prevent spread of infection. b. Monitor electrolyte balance. c. Prevent abdominal distention. d. Maintain accurate record of output. ANS: C The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can be monitored. Without the NG tube, there would be no drainage. After the NG tube is placed, it is important to maintain an accurate record of intake and output. This is not the reason for placement of the tube. DIF: Cognitive Level: Applying REF: MCS: 1077 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 10. A parent of an infant with gastroesophageal reflux asks how to decrease the number and total volume of emesis. What recommendation should the nurse include in teaching this parent? a. Surgical therapy is indicated. b. Place in prone position for sleep after feeding. c. Thicken feedings and enlarge the nipple hole. d. Reduce the frequency of feeding by encouraging larger volumes of formula. ANS: C Thickened feedings decrease the childs crying andrienacse the caloric density of the feeding. Although it does not decrease the pH, the number and volume of emesis are reduced. Surgical therapy is reserved for children who have failed to respond to medical therapy or who have an anatomic abnormality. The prone position is not recommended because of the risk of sudden infant death syndrome. Smaller, more frequent feedings are more effective than less frequent, larger volumes of formula. DIF: Cognitive Level: Applying REF: MCS: 1093 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 11. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perfsotrim at thi e? a. Notify the cptriationer. b. Insert the NG tube so feedings can be given. c. Replace the NG tube to maintain gastric decompression. d. Leave the NG tube out because it has probably been in long enough. ANS: A When surgery is performed on the upper gastrointestinal tract, usually the surgical team replaces the NG tube because of potential injury to the operative site. The decision to replace the tube or leave it out is made by the surgical team. Replacing the tube is also usually done by the practitioner because of the surgical site. DIF: Cognitive Level: Applying REF: MCS: 1077 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. An adolescent with irritable bowel syndrome comes to see the school nurse. What information should the nurse share with the adolescent? a. A low-fiber diet is required. b. Stress management may be helpful. c. Milk products are a contributing factor. d. Pantoprazole (a proton pump inhibitor) is effective in treatment. ANS: B Irritable bowel syndrome is believed to involve motor, autonomic, and psychologic factors. Stress management, environmental modification, and psychosocial intervention may reduce stress and gastrointestinal symptoms. A high-fiber diet with psyllium supplement is often beneficial. Milk products can erbxaatceebowel problems caused tobyselainctolerance. Antispasmodic drugs, antidiarrheal drugs, and simethicone are beneficial for some individuals. Proton pump inhibitors have no effect. DIF: Cognitive Level: Applying REF: MCS: 1078 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 13. What clinical manifestation should be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Colicky, cramping, abdominal pain around the umbilicus ANS: D Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain becomes constant and may shift to the right lower quadrant. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis. DIF: Cognitive Level: Understanding REF: MCS: 1079 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 14. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation? a. Anorexia b. Bradycardia c. Sudden relief from pain d. Decreased abdominal distention ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen). DIF: Cognitive Level: Applying REF: MCS: 1079 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 15. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation? a. Place in the Trendelenburg position. b. Apply moist heat to the abdomen. c. Allow the child to assume a position of comfort. d. Administer a saline enema to cleanse the bowel. ANS: C The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. If appendicitis is a possibility, administering laxative or enemas or applying heat to the area is dangerous. Such measures stimulate bowel motility and increase the risk of perforation. DIF: Cognitive Level: Applying REF: MCS: 1081 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 16. What statement oisstmde scriptive of Meckel diverticulum? a. It is acquired during childhood. b. Intestinal bleeding may be mild or profuse. c. It occurs more frequently in females than in males. d. Medical interventions are usually sufficient to treat the problem. ANS: B Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. Meckel diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 1% to 4% of the general population. It is more common in males than in females. The standard therapy is surgical removal of the diverticulum. DIF: Cognitive Level: Understanding REF: MCS: 1083 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 17. One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis (UC) is tChaist Umore like ly to cause whichiclain l manifestation? a. Pain b. Rectal bleeding c. Perianal lesions d. Growth retardation ANS: B Rectal bleeding is more common in UC than CD. Pain, perianal lesions, and growth retardation are common manifestations of CD. DIF: Cognitive Level: Understanding REF: MCS: 1084 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 18. Nutritional management of the child with Crohn disease includes a diet that has which component? a. High fiber b. Increased protein c. Reduced calories d. Herbal supplements ANS: B The child with Crohn disease often has growth failure. Nutritional support is planned to reduce ongoing losses and provide adequate energy and protein for healing. Fiber is mechanically hard to digest. Foods containing seeds may contribute to obstruction. A high-calorie diet is necessary to minimize growth failure. Herbal supplements should not be used unless discussed with the practitioner. Vitamin supplementation with folic acid, iron, and multivitamins is recommended. DIF: Cognitive Level: Understanding REF: MCS: 1086 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 19. What information should the nurse include when teaching an adolescent with Crohn disease (CD)? a. How to cope with stress and adjust to chronic illness b. Preparation for surgical treatment and cure of CD c. Nutritional guidance and prevention of constipation d. Prevention of spread of illness to others and principles of high-fiber diet ANS: A CD is a chronic illness with a variable course and many potential complications. Guidance about living with chronic illness is essential for adolescents. Stress management techniques can help with exacerbations and possible limitations caused by the illness. At this time, there is no cure for CD. Surgical intervention may be indicated for complications that cannot be controlled by medical and nutritional therapy. Nutritional guidance is an essential part of management. Constipation is not usually an issue with CD. CD is not infectious, so transmission is not a concern. A low-fiber diet is indicated. DIF: Cognitive Level: Understanding REF: MCS: 1086 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 20. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication? a. Hyperkalemia b. Hyperchloremia c. Metabolic acidosis d. Metabolic alkalosis ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely. DIF: Cognitive Level: Applying REF: MCS: 1091 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 21. What term describes invagination of one segment of bowel within another? a. Atresia b. Stenosis c. Herniation d. Intussusception ANS: D Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Atresia is the absence or closure of a natural opening in the body. Stenosis is a narrowing or constriction of the diameter of a bodily passage or iofrice. Herniation is the protrusion of an organ or part through connective tissue or through a wall of the cavity in which it is normally enclosed. DIF: Cognitive Level: Understanding REF: MCS: 1091 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 22. A school-age child with celiac disease asks for guidance about snacks that will not exacerbate the disease. What snack should the nurse suggest? a. Pizza b. Pretzels c. Popcorn d. Oatmeal cookies ANS: C Celiac disease symptoms result from ingestion of gluten. Corn and rice do not contain gluten. Popcorn or corn chips will not exacerbate the intestinal symptoms. Pizza and pretzels are usually made from wheat flour thcaont ains gluten. Also, in tehaerly st ages of celiac disease, the child may be lactose intolerant. Oatmeal contains gluten. DIF: Cognitive Level: Applying REF: MCS: 1096 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 23. An infant with short bowel syndrome is receiving total parenteral nutrition (TPN). The practitioner has added continuous enteral feedings through a gastrostomy tube. The nurse recognizes this as important for hwhr ic ? eason a. Wean the infant from TPN the next day b. Stimulate adaptation of the small intestine c. Give additional nutrients that cannot be included in the TPN d. Provide parents with hope that the child is close to discharge ANS: B Long-term survival without TPN depends on the small itenstines ability to i ncrease its absorptive capacity. iCnounotus enteral f eedings facilitate the adaptation. TPN insdiicated unt il the child is able to receive tarliltinoun via the enteral route. Before this is accomplished, the asmll intestine must adapt and increase in cell number and cell mass per villus column. TPN is formulated to meet the infants nutritional needs. Continuous enteral feedings through a gastrostomy tube is a positive sign, but the infants ability to tolerate increasing amounts of enteral nutrition is only one factor that determines readiness for discharge. DIF: Cognitive Level: Analyzing REF: MCS: 1097 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 24. Melena, the passage of black, tarry stools, suggests bleeding from which source? a. The perianal or rectal area b. The upper gastrointestinal (GI) tract c. The lower GI tract d. Hemorrhoids or anal fissures ANS: B Melena is denatured blood from the upper GI tract or bleeding gfrhotm the ri colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red. DIF: Cognitive Level: Understanding REF: MCS: 1098 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 25. A cldhiwith a cute gastrol intestina bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock? a. Restlessness b. Rapid capillary refill c. Increased temperature d. Increased blood pressure ANS: A Restlessness is an indication of impending shock in a child. Capillary refill is slowed in shock. The child will feel cool. The blood pressure initially remains within the normal range and then declines. DIF: Cognitive Level: Analyzing REF: MCS: 1099 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 26. What signs or msysmaprteomost com monly associated with the prodromal phase of acute viral hepatitis? a. Bruising and lethargy b. Anorexia and malaise c. Fatigability and jaundice d. Dark urine and pale stools ANS: B The signs and symptoms monost comm in the prodromal phase are anorexia, amisael, l ethargy, and easy fatigability. Bruising would not be an issue unless liver damage has occurred. Jaundice is a late sign and often does not occur in children. Dark urine and pale stools would occur during the onset of jaundice (icteric phase) if it occurs. DIF: Cognitive Level: Understanding REF: MCS: 1102 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. What immunization is recommended for all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines ANS: B Universal vaccination tfiotrishBepia s recommended for all newborns. Hepatitis A vaccine is recommended for infants starting at 12 months. No vaccine is currently available for hepatitis C. DIF: Cognitive Level: Understanding REF: MCS: 1103 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 28. The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What information should the nurse include? a. Advise bed rest until 1 week after the icteric phase. b. Teach infection control measures to family members. c. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice. d. Reassure the mother that hepatitis A cannot be transmitted to other family members. ANS: B Hand washing is the single most effective measure in preventing and controlling hepatitis. Hepatitis A can be transmitted through the fecaloral rteo.uF amily members must be taught preventive measures. Rest and quiet activities are essential and adjusted to tchheilds condition, but bed rest is not necessary. The child is not infectious 1 week after the onset of jaundice and may return to school as activity level allows. DIF: Cognitive Level: Applying REF: MCS: 1104 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 29. What therapeutic intervention provides the best chance of survival for a child with cirrhosis? a. Nutritional support b. Liver transplantation c. Blood component therapy d. Treatment with corticosteroids ANS: B The only successful etratment afogreelnivde-rstdisease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation reflects the failure of other medical and surgical measures to prevent or etrat cirrhr osis. Nut itional support is necessary for the child twhic isi,rrbhuots it does not stop the progression of the disease. Blood components are indicated when the liver can no longer produce clotting factors. It is supportive therapy, not curative. Corticosteroids are not used in end-stage liver disease. DIF: Cognitive Level: Understanding REF: MCS: 1105 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Physiological Integrity 30. The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula? a. Jitteriness b. Meconium ileus c. Excessive frothy saliva d. Increased need for sleep ANS: C Excessive frothy vsaalis indicativ e of a tracheoesophageal fistula. The child is unable to swallow the secretions, so rthe e are excessive amounts of saliva in the mouth. Jitteriness is associated with several disorders, including electrolyte imbalances. Meconium ileus is associated with cystic fibrosis. Increased need for sleep is not associated with a tracheoesophageal fistula. DIF: Cognitive Level: Understanding REF: MCS: 1107 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 31. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should nursing care include? a. Feed glucose water only. b. Elevate the patients head for feedings. c. Raise the patients head and give nothing by mouth. d. Avoid suctioning unless the infant is cyanotic. ANS: C When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is rimatpivee that any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should be kept eclar of secr etions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx. DIF: Cognitive Level: Analyzing REF: MCS: 1109 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 32. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include? a. Keep the tube clamped. b. Suction the tube as needed. c. Leave the tube open to gravity drainage. d. Lower the tube to a point below the level of the stomach. ANS: C In the immediate postoperative period, the gastrostomy tube is open to gravity drainage. This usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of secretions. Lowering the tube to a point below the level of the stomach would create too much pressure. DIF: Cognitive Level: Applying REF: MCS: 1110 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 33. What should preoperative care of a newborn with an anorectal malformation include? a. Frequent suctioning b. Gastrointestinal decompression c. Feedings with sterile water only d. Supine position with head elevated ANS: B Gastrointestinal decompression is an essential part of ngursi care for a newborn with an anorectal malformation. This helps alleviate intraabdominal pressure until surgical intervention. Suctioning eisssnaortynfeocr an infant with this type of anomaly. Feedings are not indicated until eitris det mined that the tgraosintestina l ctrta.cSt is inta piune tpioni w ith dheealevated is indicated for infants with a tracheoesophageal fistula, not anorectal malformations. DIF: Cognitive Level: Applying REF: MCS: 1118 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 34. A child who has just had definitive repair of a high rectal malformation is to be discharged. What should the nurse address in the discharge preparation of this family? a. Safe administration of daily enemas b. Necessity of firm stools to keep suture line clean c. Bowel training beginning as soon as the child returns home d. Changes in stooling patterns to report to the practitioner ANS: D The parents are taught to notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided because a firm stool lwl iplace strain on the suture line. Dasaailrye ecnoenmtraindicated af ter surgical repair of a rectal malformation. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the childs developmental and physiologic readiness. DIF: Cognitive Level: Applying REF: MCS: 1118 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 35. The parents of a newborn with an umbilical hernia ask about etratment opt ions. The nurses response should be based on which knowledge? a. Surgery is recommended as soon as possible. b. The defect usually resolves spontaneously by 3 to 5 years of age. c. Aggressive treatment is necessary to reduce its high mortality. d. Taping the abdomen to flatten the protrusion is sometimes helpful. ANS: B The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical hernias rarelyebpecroobmlematic. I ncarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not iaastseodcw ith a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation. DIF: Cognitive Level: Applying REF: MCS: 1114 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 36. The nurse is preparing to care for a newborn with an omphalocele. The nurse should understand that care of the infant should include what intervention? a. Initiating breast- or bottle-feedings to stabilize the blood glucose level b. Maintaining pain management with an intravenous opioid c. Covering the intact bowel with a nonadherent dressing to prevent injury d. Performing immediate surgery ANS: C Nursing care of an infant with an omphalocele includes covering the intact bowel with a nonadherent dressing to prevent injury or placing a bowel bag or moist dressings and a plastic drape if the abdominal contents are exposed. The infant is not started on any type of feeding but has a nasogastric tube placed for rgiacsdt ecompression. Pain management is started after surgery, but surgery is not done immediately after birth. The infant is medically stabilized before different surgical options are considered. DIF: Cognitive Level: Applying REF: MCS: 1113 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 37. What should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? a. The prognosis for full recovery is excellent. b. Death usually occurs by 6 months of age. c. Liver transplantation may be needed eventually. d. Children with surgical correction live normal lives. ANS: C Untreated biliary atresia results in progressive cirrhosis and death usually by 2 years of age. Surgical intervention at 8 weeks of age is associated with somewhat better outcomes. Liver transplantation is also improving outcomes for 10-year survival. Even with surgical intervention, most children require supportive therapy. With early intervention, 10-year survival rteas range from 27% to 75%. DIF: Cognitive Level: Applying REF: MCS: 1105 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 38. A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease snhuoruld the se suspect? a. Pyloric stenosis b. Intussusception c. Hirschsprung disease d. Celiac disease ANS: C The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption. DIF: Cognitive Level: Analyzing REF: MCS: 1074 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 39. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include? a. Dilating the stoma b. Assessing bowel function c. Limitation of physical activities d. Measures to prevent prolapse of the rectum ANS: B In the postoperative period, the nurse involves the parents in the care of the child with a temporary colostomy, allowing them to help with feedings and observe for signs of wound infection or irregular passage of stool (constipation or true incontinence). Some children will require daily anal dilatations in tohpeeproastive pe riod tooaivd a nastomotic sictrtures but not stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the rectum in Hirschsprung disease, just strictures. DIF: Cognitive Level: Applying REF: MCS: 1075 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 40. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention? a. Prone position b. Sterile water feedings c. Monitoring serum laboratory electrolytes d. Covering the defect with a sterile bowel bag ANS: D Initial management of a gastroschisis involves covering the exposed bowel with a transparent plastic bowel bag or loose, moist dressings. The infant cannot be placed prone, and feedings will be withheld until surgery is performed. Electrolyte laboratory values will be monitored but not before covering the defect with a sterile bowel bag. DIF: Cognitive Level: Applying REF: MCS: 1113 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 41. What is the purpose in using cimetidine (Tagamet) for gastroesophageal reflux? a. The medication reduces gastric acid secretion. b. The medication neutralizes the acid in the stomach. c. The medication increases the rate of gastric emptying time. d. The medication coats the lining of the stomach and esophagus. ANS: A Pharmacologic therapy may be used to treat infants and children with gastroesophageal reflux disease. Both H2-receptor antagonists (cimetidine [Tagamet], ranitidine [Zantac], or famotidine [Pepcid]) and proton pump inhibitors (esomeprazole [Nexium], lansoprazole [Prevacid], omeprazole [Prilosec], pantoprazole [Protonix], and rabeprazole [Aciphex]) reduce gastric hydrochloric acid secretion. DIF: Cognitive Level: Analyzing REF: MCS: 1077 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 42. A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy. The nurse should decide to advance the feeding if which occurs? a. The infants IV line has infiltrated. b. The infant has not voided since surgery. c. The infants mother states the infant is tolerating the feeding okay. d. The infant is taking the Pedialyte without vomiting or distention. ANS: D After a pyloromyotomy, feedings are usually instituted within 12 to 24 hours, beginning with clear liquids. They are offered in small quantities at frequent intervals. Supervision of feedings is an important part of postoperative care. The feedings are advanced only if the infant is taking the clear liquids without vomiting or distention. Feedings would not be advanced if the infant has not voided, the IV line becomes infiltrated, or the mother states the infant is tolerating the feedings. DIF: Cognitive Level: Applying REF: MCS: 1063 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 43. The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse suggest? a. Hamburger on a bun b. Spaghetti with meat sauce c. Corn on the cob with butter d. Peanut butter and crackers ANS: C Treatment aocf cdeisliease consist s primarily of dietary management. Although a gluten-free diet siscrpirbeed, it is difficult to remove reyve usorce o f this protein. Some patients are able to tolerate restricted amounts of gluten. Because glutenroscmcuainly in t he grains of wheat and rye lbsuot ian s maller quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods. Corn on the cob with butter would be gluten free. DIF: Cognitive Level: Applying REF: MCS: 1096 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 44. An infant with short bowel syndrome will be on total parenteral nutrition (TPN) for an extended period of time. What should the nurse monitor the infant for ? a. Central venous catheter infection, electrolyte losses, and hyperglycemia b. Hypoglycemia, catheter migration, and weight gain c. Venous thrombosis, hyperlipidemia, and constipation d. Catheter damage, red currant jelly stools, and hypoglycemia ANS: A Numerous complications are associated with short bowel syndrome and long-term TPN. Infectious, metabolic, and cteaclhcnoimplications can oc cur. Sepsis can occur earfti mproper care of the catheter. The gastrointestinal tract can also be a source of microbial seeding of the catheter. The nurse should monitor for catheter infection, electrolyte losses, and hyperglycemia. Hypoglycemia, weight gain, constipation, or red currant jelly stools are hnaortaccteristics of short bowel syndrome with extended TPN. DIF: Cognitive Level: Applying REF: MCS: 1097 TOP: NursoicnegssP:rAssessment MS C: Client Needs: Physiological Integrity 45. A cldhii s being admitted to the phoitsal with acute ga stroenteritis. The health care provider prescribes an antiemetic. What antiemetic does the nurse anticipate being prescribed? a. Ondansetron (Zofran) b. Promethazine (Phenergan) c. Metoclopramide (Reglan) d. Dimenhydrinate (Dramamine) ANS: A Ondansetron reduces the duration of vomiting in children with acute gastroenteritis. This would be the expected prescribed antiemetic. Adverse effects with earlier generation antiemetics (e.g., promethazine and metoclopramide) include somnolence, nervousness, irritability, and dystonic reactions and should not be routinely administered to children. For children who are prone to motion sickness, it is often helpful to administer an appropriate dose of dimenhydrinate (Dramamine) before a trip, but it would not be ordered as an antiemetic. DIF: Cognitive Level: Analyzing REF: MCS: 1069 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 46. The nurse should instruct parents to administer a daily proton pump inhibitor to their child with gastroesophageal reflux at which time? a. Bedtime b. With a meal c. Midmorning d. 30 minutes before breakfast ANS: D Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal. DIF: Cognitive Level: Applying REF: MCS: 1078 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 47. An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable, and there is evidence of cramping. What action should the nurse implement? a. Burp the infant. b. Withhold the next feeding. c. Vent the gastrostomy tube. d. Notify the health care provider. ANS: C If bolus feedings are initiated through a gastrostomy after a Nissen fundoplication, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus, so burping does not relieve the distention. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays increasing irritability and evidence of cramping, some relief may be provided by venting the tube. The next feeding should not be withheld, and calling the health care provider is not necessary. DIF: Cognitive Level: Applying REF: MCS: 1078 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 48. What intervention is contraindicated in a suspected case of appendicitis? a. Enemas b. Palpating the abdomen c. Administration of antibiotics d. Administration of antipyretics for fever ANS: A In any instance in which severe abdominal pain is observed and appendicitis is suspected, the nurse must be aware of the danger of administering laxatives or aesn.eSm uch measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics shouldibneisatedrmed, and antipyretics are not contraindicated. DIF: Cognitive Level: Analyzing REF: MCS: 1080 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 49. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe? a. Steatorrhea b. Clay colored c. Currant jellylike d. Loose stools with undigested food ANS: C In Meckel diverticulum the bleeding is usually painless and may be dramatic and occur as bright red or currant jellylike stools, or it mayuorcc intermittently and appear as tarry stools. The stools are not clay colored, steatorrhea, or loose with undigested food. DIF: Cognitive Level: Understanding REF: MCS: 1083 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 50. The nurse is evaluating the laboratory results of a stool sample. What is a normal finding? a. The laboratory reports a stool pH of 5.0. b. The laboratory reports a negative guaiac. c. The laboratory reports low levels of enzymes. d. The laboratory reports reducing substances present. ANS: B The normal stool finding is a negative guaiac. Stool pH should be 7.0 to 7.5. A stool pH <5.0 is suggestive of carbohydrate malabsorption; colonic bacterial fermentation produces short-chain fatty acids, which lower stool pH. There should be no enzymes or reducing substances present in a normal stool sample. DIF: Cognitive Level: Analyzing REF: MCS: 1056 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity MULTIPLE RESPONSE 1. The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. What instructions should the nurse include? (Select all that apply.) a. Elevate the head of the bed in the crib to a 90-degree angle while the infant is sleeping. b. Hold the infant in the prone position after a feeding. c. Discontinue breastfeeding so that a formula and rice cereal mixture can be used. d. The infant will require the Nissen fundoplication after 1 year of age. e. Prescribed cimetidine (Tagamet) should be given 30 minutes before feedings. ANS: B, E Discharge instructions for an infant with GER should include the prone position h(uep on t shoulder or across the lap) after a feeding. Use of the prone position while the infant is sleeping is still controversial. The American Academy of Pediatrics recommends the supine position to decrease the risk of sudden infant death syndrome even in infants with GER. Prescribed cimetidine or another proton pump inhibitor should be given 30 minutes before the morning and evening feeding so that peak plasma concentrations occur with mealtime. The head of the bed in the crib does not need to be elevated. The mother may continue to breastfeed or express breast milk to add rice cereal iformecmended by the lhtehac reap rovider; thickening breast milk or formula with cereal is not recommended by all practitioners. The Nissen fundoplication is only done on infants with GER in severe cases with complications. DIF: Cognitive Level: Applying REF: MCS: 1078 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 2. The nurse is preparing to admit a 3-year-old child with einpttuiossnu. sWc hat clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Absent bowel sounds b. Passage of red, currant jellylike stools c. Anorexia d. Tender, distended abdomen e. Hematemesis f. Sudden acute abdominal pain ANS: B, D, F Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it and leading to obstruction. Clinical manifestations of intussusception include the passage of red, currant jellylike stools; a tender, distended abdomen; and sudden acute abdominal pain. Absent bowel sounds, anorexia, and hematemesis are clinical manifestations observed in other types of gastrointestinal dysfunction. DIF: Cognitive Level: Applying REF: MCS: 1093 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Physiological Integrity 3. The school nurse is teaching a group of adolescents about avoiding contaminated water during a mission trip. What should the nurse include in the teaching? (Select all that apply.) a. Ice b. Meats c. Raw vegetables d. Unpeeled fruits e. Carbonated beverages ANS: A, B, C, D The best measure during travel to areas where water may be contaminated is to allow children to drink only bottled water and carbonated beverages (from the container through a straw supplied from home). Children should also avoid tap water, ice, unpasteurized dairy products, raw vegetables, unpeeled fruits, meats, and seafood. DIF: Cognitive Level: Applying REF: MCS: 1102 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. The nurse is teaching parents about high-fiber foods that can prevent constipation. What foods should the nurse include in the teaching? (Select all that apply.) a. Oranges b. Bananas c. Lima beans d. Baked beans e. Raisin bran cereal ANS: C, D, E Lima beans have 13.2 g of fiber in 1 cup, baked beans have 10.4 g of fiber in 1 cup, and raisin bran cereal has 7.3 g of fiber in 1 cup. One orange has only 3.1 g of fiber, and 1 banana has only 3.1 g of fiber, so they are not recommended as high-fiber foods. DIF: Cognitive Level: Applying REF: MCS: 1073 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is teaching parents of a child with gastroesophageal reflux (GER) disease foods that can exacerbate acid reflux. What foods should be included in the teaching session? (Select all that apply.) a. Citrus b. Bananas c. Spicy foods d. Peppermint e. Whole wheat bread ANS: A, C, D Avoidance of certain foods that exacerbate acid reflux (e.g., caffeine, citrus, tomatoes, alcohol, peppermint, spicy or fried foods) can improve mild GER symptoms. Bananas and whole wheat bread will not exacerbate acid reflux. DIF: Cognitive Level: Applying REF: MCS: 1076 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. The nurse is preparing to admit a 6-year-old child with irritable bowel syndrome (IBS). What clinical manifestations should the nurse expect tovoeb?se(Srelect a ll that apply.) a. Flatulence b. Constipation c. No urge to defecate d. Absence of abdominal pain e. Feeling of incomplete evacuation of the bowel ANS: A, B, E Children with IBS often have alternating diarrhea and constipation, flatulence, bloating or a feeling of abdominal distention, lower abdominal pain, a feeling of urgency when needing to defecate, and a feeling of incomplete evacuation of the bowel. DIF: Cognitive Level: Applying REF: MCS: 1078 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 7. The nurse is caring for a child with caecldi isease. T he nurse understands that what may precipitate a celiac crisis? (Select all that apply.) a. Exercise b. Infections c. Fluid overload d. Electrolyte depletion e. Emotional disturbance ANS: B, D, E A celiac crisis can be precipitated by infections, electrolyte depletion, and emotional disturbance. Exercise or fluid overload does not precipitate a crisis. DIF: Cognitive Level: Understanding REF: MCS: 1096 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. The nurse is preparing to admit a 6-year-old child with celiac disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Steatorrhea b. Polycythemia c. Malnutrition d. Melena stools e. Foul-smelling stools ANS: A, C, E Clinical manifestations of celiac disease include impaired fat iaobnsorpt (steatorrhea and foul- smelling stools) and impaired nutrient absorption (malnutrition). Anemia, not polycythemia, is a manifestation, and melena stools do not occur. DIF: Cognitive Level: Applying REF: MCS: 1096 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. The nurse is preparing to admit a 10-year-old child with appendicitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Fever b. Vomiting c. Tachycardia d. Flushed face e. Hyperactive bowel sounds ANS: A, B, C Clinical manifestations of appendicitis include fever, vomiting, and tachycardia. lPoarl i s seen, not a flushed face, and the bowel sounds are hypoactive or absent, not hyperactive. DIF: Cognitive Level: Applying REF: MCS: 1079 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. The nurse is preparing to admit a 2-month-old child with hypertrophic pyloric stenosis. What clinical manifestations should the nurse expect tovoeb?se(Srelect all that apply.) a. Weight loss b. Bilious vomiting c. Abdominal pain d. Projectile vomiting e. The infant is hungry after vomiting ANS: A, D, E Clinical manifestations of hypertrophic pyloric stenosis include weight loss, projectile vomiting, and hunger after vomiting. The vomitus is nonbilious, and there is no evidence of pain or discomfort, just chronic hunger. DIF: Cognitive Level: Applying REF: MCS: 1092 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. The nurse is preparing to admit a 6-month-old child with gastroesophageal reflux disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Spitting up b. Bilious vomiting c. Failure to thrive d. Excessive crying e. Respiratory problems ANS: A, C, D, E Clinical manifestations of gastroesophageal reflux disease include spitting up, failure to thrive, excessive crying, and respiratory problems. Hematemesis, not bilious vomiting, is a manifestation. DIF: Cognitive Level: Applying REF: MCS: 1076 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 12. The nurse is preparing to admit a 5-year-old child with pheatitis A . What clinical features of hepatitis A should the nurse recognize? (Select all that apply.) a. The onset is rapid. b. Fever occurs early. c. There is usually a pruritic rash. d. Nausea and vomiting are common. e. The mode of transmission is primarily by the parenteral route. ANS: A, B, D Clinical features of hepatitis A include a rapid onset, fever occurring early, and nausea and vomiting. A rash is rare, and the mode of transmission is by the fecaloral route, rarely by the parenteral route. DIF: Cognitive Level: Understanding REF: MCS: 1101 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. The nurse is preparing to admit a 7-year-old child with pheatitis B . What clinical features of hepatitis B should the nurse recognize? (Select all that apply.) a. The onset is rapid. b. Rash is common. c. Jaundice is present d. No carrier state exists. e. The mode of transmission is principally by the parenteral route. ANS: B, C, E Clinical features of hepatitis B include a rash, jaundice, and the mode of transmission principally by the parenteral route. The onset is insidious, not rapid, and a carrier state does exist. DIF: Cognitive Level: Understanding REF: MCS: 1101 TOP: Nursing Process: Assessment MSC: Client eNdes: Physiologica l Integrity 14. The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Pain is common. b. Weight loss is severe. c. Rectal bleeding is common. d. Diarrhea is moderate to severe. e. Anal and perianal lesions are rare. ANS: A, B, D Clinical manifestations of Crohn disease include pain, severe weight loss, and moderate to severe diarrhea. Rectal bleeding is rare, but anal and perianal lesions are common. DIF: Cognitive Level: Applying REF: MCS: 1085 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity COMPLETION 1. The health care provider has prescribed ondansetron (Zofran) 0.1 mg/kg as needed for nausea for a child admitted for vomiting. The child weighs 55 lb. Calculate the correct dose of Zofran in milligrams. Record your answer using one decimal place. ANS: 2.5 The correct calculation is: 55 lb/2.2 kg = 25 kg Dose of Zofran is 0.1 mg/kg 0.1 mg 25 = 2.5 mg DIF: Cognitive Level: Applying REF: MCS: 1069 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The health care provider has prescribed metronidazole (Flagyl) 30 mg/kg a day divided q 6 hours for a child with peptic ulcer disease. The child weighs 110 lb. The nurse is preparing to administer the 1200 dose. Calculate the dose the nurse should administer in mg. Record your answer in a whole number. ANS: 375 The correct calculation is: 110 lb/2.2 kg = 50 kg Dose of Flagyl: 30 mg/kg a day 30 mg 50 = 1500 mg a day 1500 mg/4 = 375 mg for one dose. DIF: Cognitive Level: Applying REF: MCS: 1086 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The health care provider has prescribed clarithromycin (Biaxin) 20 mg/kg/day divided bid for a child with peptic ulcer disease. The child weighs 77 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer in a whole number. ANS: 350 The correct calculation is: 77 lb/2.2 kg = 35 kg Dose of Biaxin is 20 mg/kg/day divided bid 20 mg 35 = 700 mg 700 mg/2 = 350 mg for one dose DIF: Cognitive Level: Applying REF: MCS: 1090 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. The health care provider has prescribed famotidine (Pepcid) 1 mg/kg/day divided bid for a child with gastroesophageal reflux disease. The child weighs 33 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer using one decimal place. ANS: 7.5 The correct calculation is: 33 lb/2.2 kg = 15 kg Chapter 26.The Child with Respiratory Dysfunction MULTIPLE CHOICE 1. Why are cool-mist vaporizers rather than steam vaporizers recommended in the home treatment of respiratory infections? a. They are safer. b. They are less expensive. c. Respiratory secretions are dried by steam vaporizers. d. A more comfortable environment is produced. ANS: A Cool-mist vaporizers are safernthsateam va porizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam ivzaeprosri s comparable. Seatm loosens secretions, not dries them. Both cool-mist vaporizers amdvsate porizers may promote a more comfortable environment, but cool-mist vaporizers have decreased risk for burns and growth of organisms. DIF: Cognitive Level: Understanding REF: MCS: 1165 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include which information? a. Do not use for more than 3 days. b. Keep drops to use again for nasal congestion. c. Administer drops after feedings and at bedtime. d. Give two drops every 5 minutes until nasal congestion subsides. ANS: A Vasoconstrictive nose drops such as Neo-Synephrine should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness and not used for other children because they may become contaminated with beraicat. D rops administered before feedings are more helpful. Two drops are administered to cause vasoconstriction in the anterior mucous membranes. An additional two drops are instilled 5 to 10 minutes later for the posterior mucous membranes. No further doses should be given. DIF: Cognitive Level: Applying REF: MCS: 1170 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 3. The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant shows signs or symptoms of which condition? a. Has a cough b. Becomes fussy c. Shows signs of an earache d. Has a fever higher than 37.5 C (99 F) ANS: C If an infant with nasopharyngitis shows signs of an earache, it may indicate respiratory complications and possibly secondary bacterial infection. The health professional should be contacted to evaluate the infant. Cough can be a sign of nasopharyngitis. Irritability is common in an infant with a viral illness. Fever is common in viral illnesses. DIF: Cognitive Level: Applying REF: MCS: 1171 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 4. It is important that a child with raecputtoecsotccal pharyngitis b e treated with antibiotics to prevent which condition? a. Otitis media b. Diabetes insipidus (DI) c. Nephrotic syndrome d. Acute rheumatic fever ANS: D Group A hoelymtic s treptococcal infection is a brief illness with varying symptoms. It is essential that pharyngitis caused by this organism be treated with appropriate antibiotics to avoid the sequelae of acute rheumatic fever and acute glomerulonephritis. The cause of otitis media is either viral or other bacterial organisms. DI is a disorder of the rpioosrtepituitary. Infections such as meningitis or encephalitis, not streptococcal pharyngitis, can cause DI. Glomerulonephritis, not nephrotic syndrome, can result from acute streptococcal pharyngitis. DIF: Cognitive Level: Understanding REF: MCS: 1171 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 5. When caring for a child after a tonsillectomy, what intervention should the nurse do? a. Watch for continuous swallowing. b. Encourage gargling to reduce discomfort. c. Apply warm compresses to the throat. d. Position the child on the back for sleeping. ANS: A Continuous swallowing, especially while sleeping, is an early sign of bleeding. The child swallows the blood thias trickling from the operative site. Gargling is discouraged because it could irritate the operative site. Ice compresses are recommended tocreedinuflammation. The child should be positioned on the side or abdomen to facilitate drainage of secretions. DIF: Cognitive Level: Applying REF: MCS: 1174 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. What statement best represents infectious mononucleosis? a. Herpes simplex type 2 is the principal cause. b. A complete blood count shows a characteristic leukopenia. c. A short course of ampicillin is used when pharyngitis is present. d. Clinical signs and symptoms and blood tests are both needed to establish the diagnosis. ANS: D The characteristics of the diseasemalaise, sore throat, lymphadenopathy, central nervous system manifestations, and skin lesionsare similar to presenting signs and symptoms in other diseases. Hematologic analysis (heterophil antibody and monospot) can help confirm the diagnosis. However, not all young children develop the expected laboratory findings. Herpes-like tEepins - Barr virus is tphreincipal caus e. aUlslyu, an increase in lymphocytes is observed. Penicillin, not ampicillin, is indicated. Ampicillin itsh laindkiescdrewtei macular eruption in infectious mononucleosis. DIF: Cognitive Level: Understanding REF: MCS: 1176 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. Parents bring their 15-month-old infant to the emergency department at 3:00 AM because the toddler has a temperature of 39 C (102.2 F), is crying inconsolably, and is tugging at the ears. A diagnosis of otitis media (OM) is made. In addition to antibiotic therapy, the nurse practitioner should instruct the parents to use what medication? a. Decongestants to ease stuffy nose b. Antihistamines to help the child sleep c. Aspirin for pain and fever management d. Benzocaine ear drops for topical pain relief ANS: D Analgesic ear drops can provide topical relief for the intense pain of OM. Decongestants and antihistamines are not recommended in the treatment of OM. Aspirin is contraindicated in young children because of the association with Reye syndrome. DIF: Cognitive Level: Applying REF: MCS: 1181 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 8. An 18-month-old child is seen in the iccliwn ith iostimt edia (OM). Ol arma oxicillin is prescribed. What instructions should be given to the parent? a. Administer all of the prescribed medication. b. Continue medication until all symptoms subside. c. Immediately stop giving medication if hearing loss develops. d. Stop giving medication and come to the clinic if fever is still present in 24 hours. ANS: A Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication of OM; antibiotics should continue to be given. Medication may take 24 to 48 hours to make symptoms subside. DIF: Cognitive Level: Applying REF: MCS: 1182 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 9. An infants parents ask the nurse about preventing otitis media (OM). What information should be provided? a. Avoid tobacco smoke. b. Use nasal decongestants. c. Avoid children with OM. d. Bottle- or breastfeed in a supine position. ANS: A Eliminating tobacco smoke from the childs environment is essential for preventing OM and other common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious unless they show other symptoms of upper respiratory tract infection. Children should be fed in a semivertical position to prevent OM. DIF: Cognitive Level: Applying REF: MCS: 1182 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 10. Chronic otitis media with feufsion (OME) differs from acute otitis dmiea (A OM) because it is usually characterized by which signs or symptoms? a. Severe pain in the ear b. Anorexia and vomiting c. A feeling of fullness in the ear d. Fever as high as 40 C (104 F) ANS: C OME is characterized by a feeling of nfuelsls in the ear o r other nonspecific complaints. OME does not cause severe pain. This may be a sign of AOM. Vomiting, anorexia, and fever are associated with AOM. DIF: Cognitive Level: Understanding REF: MCS: 1180 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. A 4-year-old girl is brought to the emergency department. She has a froglike croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should intervene in which manner? a. Make her lie down and rest quietly. b. Examine her oral pharynx and report to the physician. c. Auscultate her lungs and prepare for placement in a mist tent. d. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation. ANS: D This child is exhibiting signs of respiratory distress and possible epiglottitis. Epiglottitis is always daimcae l emergency requiring antibiotics and airway support for treatment. Sitting up is the position that facilitates breathing in respiratory disease. The oral pharynx should not be visualized. If the epiglottis is inflamed, there is the potential for complete obstruction if it is irritated further. Although lung auscultation provides useful assessment information, a mist tent would not be beneficial for this child. Immediate medical evaluation and intervention are indicated. DIF: Cognitive Level: Applying REF: MCS: 1185 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 12. The nurse is assessing a child with croup in the emergency department. The child has a sore throat and is drooling. Examining the childs throat using a tongue depressor might precipitate what condition? a. Sore throat b. Inspiratory stridor c. Complete obstruction d. Respiratory tract infection ANS: C If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Sore throat and pain on swallowing are early signs of epiglottitis. Sritdor is aggravated when a child with iegplottitis is supine. Epiglottitis is caused by Haemophilus influenzae in the respiratory tract. DIF: Cognitive Level: Understanding REF: MCS: 1185 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37 C (98.6 F). The nurse suspects mild croup and should recommend which intervention? a. Admit to the hospital and observe for impending epiglottitis. b. Provide fluids that the child likes and use comfort measures. c. Control fever with acetaminophen and call if cough gets worse tonight. d. Try over-the-counter cough medicine and come to the clinic tomorrow if no improvement. ANS: B In mild croup, therapeutic interventions include adequate hydration (as long as the child can easily drink) and comfort measures to minimize distress. The child is not exhibiting signs of epiglottitis. A temperature of 37 C is within normal limits. Although a return to the clinic may be indicated, the mother is instructed to return if the child develops noisy respirations or drooling. DIF: Cognitive Level: Applying REF: MCS: 1184 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 14. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis to stay at the bedside as much as possible. What is the primary rationale for this action? a. Mothers of hospitalized toddlers often experience guilt. b. The mothers presence will reduce anxiety and ease the childs respiratory efforts. c. Separation from the mother is a major developmental threat at this age. d. The mother can provide constant observations of the childs respiratory efforts. ANS: B The familys presence will decrease the childs distress. It is true that mothers of hospitalized toddlers often experience guilt tansedptahraation from mother is a major developmental threat for toddlers, but the main reason to keep parents at the childs bedside is to ease anxiety and therefore respiratory effort. DIF: Cognitive Level: Applying REF: MCS: 1186 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 15. An infant with bronchiolitis is hospitalized. The causative noirsgma is re spiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires what type of isolation? a. Reverse isolation b. Airborne isolation c. Contact Precautions d. Standard Precautions ANS: C RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are regqiuvireersd.mCuast use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne. DIF: Cognitive Level: Applying REF: MCS: 1189 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 16. An infant has been diagnosed with staphylococcal pneumonia. Nursing care of the child with pneumonia includes which intervention? a. Administration of antibiotics b. Frequent complete assessment of the infant c. Round-the-clock administration of antitussive agents d. Strict monitoring of intake and output to avoid congestive heart failure ANS: A Antibiotics are indicated for bacterial pneumonia. Often the child has decreased pulmonary reserve, and clustering of care is essential. The childs respiratory rate and status and general disposition are monitored closely, but frequent complete physical assessments are not indicated. Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential to kept secretions as liquefied as possible. DIF: Cognitive Level: Applying REF: MCS: 1193 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 17. What consideration is most important in managing tuberculosis (TB) inlcdhrein? a. Skin testing b. Chemotherapy c. Adequate rest d. Adequate hydration ANS: B Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and isoniazid and rifampin given two or three times a week by direct observation therapy for the remaining 4 months. Chemotherapy is the most important intervention for TB. DIF: Cognitive Level: Applying REF: MCS: 1200 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. A toddler has a unilateral foul-smelling nasal discharge and frequent sneezing. The nurse should suspect what condition? a. Allergies b. Acute pharyngitis c. Foreign body in the nose d. Acute nasopharyngitis ANS: C The irritation of a foreign body in the nose produces local mucosal swelling with foul-smelling nasal discharge, local obstruction with sneezing, and mild discomfort. Allergies would produce clear bilateral nasal discharge. Nasal discharge is usually not associated with pharyngitis. Acute nasopharyngitis would have bilateral mucous discharge. DIF: Cognitive Level: Analyzing REF: MCS: 1202 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 19. The nurse is caring for tahcahciludt wi e respiratory distress syndrome (ARDS) associated with sepsis. What nursing action should be included in the care of the child? a. Force fluids. b. Monitor pulse oximetry. c. Institute seizure precautions. d. Encourage a high-protein diet. ANS: B Careful monitoring of oxygenation and cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful. DIF: Cognitive Level: Applying REF: MCS: 1207 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 20. The nurse is caring for a child with carbon monoxide (CO) poisoning associated with smoke inhalation. What intervention is seesntial in tlhdiss chi care? a. Monitor pulse oximetry. b. Monitor arterial blood gases. c. Administer oxygen if respiratory distress develops. d. Administer oxygen if childs lips become bright, cherry-red in color. ANS: B Arterial blood gases are the best way to monitor CO poisoning. Pulse oximetry is contraindicated in the case of CO poisoning because the PaO2 may be normal. One hundred percent oxygen should be given as quickly as possible, not only if respiratory distress or other symptoms develop. DIF: Cognitive Level: Applying REF: MCS: 1208 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 21. What diagnostic test for allergs itehseinvolve injection of specific allergens? a. Phadiatop b. Skin testing c. Radioallergosorbent tests (RAST) d. Blood examination for total immunoglobulin E (IgE) ANS: B Skin testing tis the mos commonly used diagnostic test for allergy. A specific allergen is injected under the skin, earnda asuftitable time, the size of the resultant wheal is measured to determine the patients sensitivity. Phadiatop is a screening test that uses a blood sample to assess for IgE antibodies for a group of fsipceaclilergens. R AST determines the level of fsipceIcgiE antibodies. Blood examination for total IgE would not distinguish among allergens. DIF: Cognitive Level: Understanding REF: MCS: 1214 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. What statement hisetmost de scriptive of asthma? a. It is inherited. b. There is heightened airway reactivity. c. There is decreased resistance in the airway. d. The single cause of asthma is an allergic hypersensitivity. ANS: B In asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. Atopy, or development of an immunoglobulin E (IgE)mediated response, is inherited but is not the only cause of asthma. Asthma is characterized by increased resistance in the airway. Asthma has multiple causes, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. DIF: Cognitive Level: Understanding REF: MCS: 1216 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 23. What condition is the leading cause of chronic illness in children? a. Asthma b. Pertussis c. Tuberculosis d. Cystic fibrosis ANS: A Asthma is the most common chronic disease of childhood, the primary cause of school absences, and the third leading cause of hospitalization in children younger than the age of 15 years. Pertussis is not a chronic illness. Tuberculosis is not a significant factor in childhood chronic illness. Cystic fibrosis is the most common lethal genetic illness among white children. DIF: Cognitive Level: Understanding REF: MCS: 1215 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 24. A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration. This suggests what condition? a. Asthma b. Pneumonia c. Bronchiolitis d. Foreign body in trachea ANS: A Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset, fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial virus. Foreign body in the trachea occurus twe irtehspaciratory distress or f ailure and maybe stridor. DIF: Cognitive Level: Understanding REF: MCS: 1215 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 25. A child with asthma is having pulmonary function tests. What rationale explains the purpose of the peak expiratory flow rate? a. To assess severity of asthma b. To determine cause of asthma c. To identify triggers of asthma d. To confirm diagnosis of asthma ANS: A Peak expiratory flow rate monitoring is used to monitor the childs current pulmonary function. It can be used to manage exacerbations and for daily long-term management. The cause of asthma is known. Asthma is caused by a complex interaction among inflammatory cells, mediators, and the cells and tissues present in the airways. Ttrhieggers of asthma are determined through history taking and immunologic and other testing. The diagnosis of asthma is made through clinical manifestations, history, physical examination, and laboratory testing. DIF: Cognitive Level: Analyzing REF: MCS: 1220 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 26. Children who are taking long-term inhaled steroids should be assessed frequently for what potential complication? a. Cough b. Osteoporosis c. Slowed growth d. Cushing syndrome ANS: C The growth of children on long-term inhaled steroids should be assessed frequently to evaluate systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids. DIF: Cognitive Level: Understanding REF: MCS: 1223 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 27. One of the goals for children with asthma is to maintain the childs normal functioning. What principle of treatment helps to accomplish this goal? a. Limit participation in sports. b. Reduce underlying inflammation. c. Minimize use of pharmacologic agents. d. Have yearly evaluations by a health care provider. ANS: B Children with asthma are often excluded from exercise. This practice interferes with peer interaction and physical health. Mldroesnt wchiith asthma can participate provided their asthma is under control. Inflammation is the iunnderly g cause of the symptoms of asthma. Byedaescinrg inflammation and reducing the symptomatic airway narrowing, health care providers can minimize exacerbations. Pharmacologic agents are used tovpernet and control asthma symptoms, reduce the frequency and severity of asethxmacerbations, an drrseevaeirflow obstruction. It is recommended that children with asthma be evaluated every 6 months. DIF: Cognitive Level: Analyzing REF: MCS: 1221 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 28. What drug is usually given first in the emergency treatment of an acute, severe asthma episode in a young child? a. Ephedrine b. Theophylline c. Aminophylline d. Short-acting 2-agonists ANS: D Short-acting 2-agonists are the first treatment in an acute asthma exacerbation. Ephedrine and aminophylline are not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations. DIF: Cognitive Level: Applying REF: MCS: 1222 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 29. Cystic fibrosis (CF) may affect single or multiple systems of the body. What is the primary factor responsible for possible multiple clinical manifestations in CF? a. Hyperactivity of sweat glands b. Hypoactivity of autonomic nervous system c. Atrophic changes in mucosal wall of intestines d. Mechanical obstruction caused by increased viscosity of mucous gland secretions ANS: D The mucous glands produce a thick mucoprotein that accumulates and results in dilation. Small passages in organs such as the pancreas and bronchioles become obstructed as secretions form concretions in the glands and ducts. The exocrine glands, not sweat glands, are dysfunctional. Although abnormalities in the autonomic nervous system are present, it is not hypoactive. Intestinal involvement in CF reuslts from the blockage and rectal prolapse. cthki intestinal secretions, which can lead to DIF: Cognitive Level: Understanding REF: MCS: 1235 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 30. What is the relaiest recognizable c linical manifestation(s) of cystic fibrosis (CF)? a. Meconium ileus b. History of poor intestinal absorption c. Foul-smelling, frothy, greasy stools d. Recurrent pneumonia and lung infections ANS: A The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with .CF Clinical manifestations liuncde a bdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a rlastiegn that manifests as failure to thrive. Foul-smelling stools and recurrent respiratory infections are tlaer manifestations of CF. DIF: Cognitive Level: Understanding REF: MCS: 1236 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 31. What tests aid in the diagnosis of cystic fibrosis )(?CF a. Sweat test, stool for fat, chest radiography b. Sweat test, bronchoscopy, duodenal fluid analysis c. Sweat test, stool for trypsin, biopsy of intestinal mucosa d. Stool for fat, gastric contents for hydrochloride, radiography ANS: A A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a gastrointestinal manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Bronchoscopy, duodenal fluid analysis, stool tests for trypsin, and intestinal biopsy are not helpful in diagnosing CF. Gastric contents normally contain hydrochloride; it is not diagnostic. DIF: Cognitive Level: Applying REF: MCS: 1237 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 32. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? a. After chest physiotherapy (CPT) b. Before chest physiotherapy (CPT) c. After receiving 100% oxygen d. Before receiving 100% oxygen ANS: B Bronchodilators should be given before CPT to open bronchi and make expectoration easier. These medications are not helpful ewnhus ed after .COPTxygen is administered only in acute episodes, with caution, because of chronic carbon dioxide retention. DIF: Cognitive Level: Applying REF: MCS: 1238 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 33. A cldhiwith c ystic rfiebcreoivsis is What statement asbeouist tDruNe? ng recombinant human deoxyribonuclease (DNase). a. Given subcutaneously b. May cause voice alterations c. May cause mucus to thicken d. Not indicated for children younger than age 12 years ANS: B One of tohnely adve rse effects of DNase is voice alterations and laryngitis. aDsNe i s given in an aerosolized form, decreases the viscosity of mucus, and is safe for children younger than 12 years. DIF: Cognitive Level: Understanding REF: MCS: 1238 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 34. The nptaroef a child withtcicysf ibrosis (CF) calls the clinic nurse to report that ltdhehchi as developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these signs and symptoms are suggestive of twha condition? a. Pneumothorax b. Bronchodilation c. Carbon dioxide retention d. Increased viscosity of sputum ANS: A Usually the signs of pneumothorax are nonspecific. Tachypnea, tachycardia, dyspnea, pallor, and cyanosis are significant signs and symptoms and are indicative of respiratory distress caused by pneumothorax. If the bronchial tubes were dilated, the child would have decreased work of breathing and would most likely be asymptomatic. Carbon dioxide retention is a result of the chronic alveolar hypoventilation in CF. Hypoxia replaces carbon dioxide as the drive for respiration progresses. Increased viscosity would result in more difficulty clearing secretions. DIF: Cognitive Level: Applying REF: MCS: 1239 TOP: Nursing Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 35. Pancreatic enzymes are administered to the child with cystic fibrosis. What nursing consideration should be included in the plan of care? a. Give pancreatic enzymes between meals if at all possible. b. Do not administer pancreatic enzymes if the child is receiving antibiotics. c. Decrease the dose of pancreatic enzymes if the child is having frequent, bulky stools. d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal. ANS: D Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Enzymes should be givensjtube fore meals and snacks. Pancreatic enzymes are not a contraindication for antibiotics. The dose of enzymes should be increased if child is having frequent, bulky stools. DIF: Cognitive Level: Applying REF: MCS: 1240 TOP: NursoicnegssP:rImplementation MSC: Client Needs: Physiological Integrity 36. The nurse is giving discharge instructions to the parents of a 5-year-old child who had a tonsillectomy 4 hours ago. What statement by the parent indicates a correct understanding of the teaching? a. I can use an ice collar on my child for pain control along with analgesics. b. My child should clear the throat frequently to clear the secretions. c. I should allow my child to be as active as tolerated. d. My child should gargle and brush teeth at least three times per day. ANS: A Pain control after a tonsillectomy can be achieved with application of an ice collar and administration of analgesics. The child should avoid clearing the throat or coughing and does not need to gargle and brush teeth a certain number of times per day and should avoid vigorous gargling and toothbrushing. Also, the childs activity should be limited to decrease the potential for bleeding, at least for the first few days. DIF: Cognitive Level: Applying REF: MCS: 1174 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 37. A cldhii s admitted with uacte l aryngotracheobronchitis (LTB). The lcdhiw treated cwhi?th whi l milost likely be a. Racemic epinephrine and corticosteroids b. Nebulizer treatments and oxygen c. Antibiotics and albuterol d. Chest physiotherapy and humidity ANS: A Nebulized epinephrine (racemic epinephrine) is now used in children with LTB that is not alleviated with lcomoist. T he dbreetan-eargic effects caus e mucosal ovnasotrciction and subsequent decreased subglottic edema. Te hus e of corticosteroids is beneficial because the anti- inflammatory effects decrease subglottic edema. iNzer ut l reatments are encottiveeffeven though oxygen may be required. Antibiotics are not used because it is a viral infection. Chest physiotherapy would not be instituted. DIF: Cognitive Level: Applying REF: MCS: 1186 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 38. A 6-year-old child has had a tonsillectomy. The child is spitting up small amounts of dark brown blood in the immediate postoperative period. The nurse should take what action? a. Notify the ahleth care p rovider. b. Continue to assess for bleeding. c. Give the child a red flavored ice pop. d. Position the child in a Trendelenburg position. ANS: B Some secretions, particularly dried blood from surgery, are common after a tonsillectomy. Inspect all secretions and vomitus for evidence of fresh bleeding (some blood-tinged mucus is expected). Dark brown (old) blood is usually present in the emesis, as well as in the nose and between the teeth. Small amounts of dark brown blood should be further monitored. A red- flavored ice pop should not be given and the Trendelenburg position is not recommended. DIF: Cognitive Level: Applying REF: MCS: 1175 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 39. A 3-year-old child is experiencing pain after a tonsillectomy. The child has not taken in any fluids and does not want to drink anything, saying, My tummy hurts. The following health care prescriptions are available: acetaminophen (Tylenol) PO (ollrya) or PR (r ectally) PRN, ice chips, clear liquids. What should the nurse implement to relieve the childs pain? a. Ice chips b. Tylenol PO c. Tylenol PR d. Popsicle ANS: C The throat is very sore after a tonsillectomy. Most children experience moderate pain after a tonsillectomy and need pain medication at regular intervals for at least the first 24 hours. Analgesics may need to be given rectally or intravenously to avoid the oral route. DIF: Cognitive Level: Applying REF: MCS: 1169 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 40. A 1-year-old child has acute otitis media (AOM) and is being treated with oral antibiotics. What should the nurse include in the discharge teaching to the infants parents? a. A follow-up visit should be done after all medicine has been given. b. After an episode of acute otitis media, hearing loss usually occurs. c. Tylenol should not be given because it may mask symptoms. d. The infant will probably need a myringotomy procedure and tubes. ANS: A Children with AOM should be seen after antibiotic therapy is complete to evaluate the effectiveness of tthreatment and toiifdyepnot tential complications, such as effusion or hearing impairment. Hearing loss does not usually occur with acute otitis media. Tylenol should be given for pain, and the infant will not necessarily need a myringotomy procedure. DIF: Cognitive Level: Applying REF: MCS: 1178 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 41. What do the initial signs of respiratory syncytial virus (RSV) infection in an infant include? a. Rhinorrhea, wheezing, and fever b. Tachypnea, cyanosis, and apnea c. Retractions, fever, and listlessness d. Poor breath sounds and air hunger ANS: A Symptoms such as rhinorrhea and a low-grade fever often appear first. OM and conjunctivitis may also be present. In time, a cough may develop. Wheezing is an initial sign as well. Progression of illness brings on the symptoms of tachypnea, retractions, poor breath sounds, cyanosis, air hunger, and apnea. DIF: Cognitive Level: Applying REF: MCS: 1180 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 42. The nurse is caring for a 1-month-old infant with respiratory syncytial virus (RSV) who is receiving 23% oxygen via a plastic hood. The childs SaO2 saturation is 88%, respiratory rate is 45 breaths/min, and pulse is 140 beats/min. Based on these assessments, what action should the nurse take? a. Withhold feedings. b. Notify the health care provider. c. Put the infant in an infant seat. d. Keep the infant in the plastic hood. ANS: B The American Academy of Pediatrics practice parameter (2006) mreecnodms the use of supplemental oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90%. The health care provider should be notified of the saturation reading of 88%. Withholding the feedings or placing the infant inaannt inf dsenaot woul t increase the saturation reading. The infant should be kept in the hood, but because the saturation reading is 88%, the health care provider should be notified to obtain orders to increase the oxygen concentration. DIF: Cognitive Level: Applying REF: MCS: 1189 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 43. A 5-year-old child is admitted with bacterial pneumonia. What signs and symptoms should the nurse expect to assess with this disease process? a. Fever, cough, and chest pain b. Stridor, wheezing, and ear infection c. Nasal discharge, headache, and cough d. Pharyngitis, intermittent fever, and eye infection ANS: A Children with bacterial pneumonia usually appear ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. Ear infection, nasal discharge, and eye infection are not symptoms of bacterial pneumonia. DIF: Cognitive Level: Applying REF: MCS: 1193 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 44. An infant with a congenital heart defect is to receive a dose of palivizumab (Synagis). What is the purpose of this? a. Prevent RSV infection. b. Prevent secondary bacterial infection. c. Decrease toxicity of antiviral agents. d. Make isolation of infant with RSV unnecessary. ANS: A The only product available in the United States for prevention of RSV is palivizumab, a humanized mouse monoclonal antibody, which is given once every 30 days (15 mg/kg) between November and March. It is given to high-risk infants, which includes an infant with a congenital heart defect. DIF: Cognitive Level: Understanding REF: MCS: 1190 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 45. A 3-year-old is brought to the emergarency dep tment with symptoms of stridor, vfeer, restlessness, and drooling. No coughing is observed. Based on these findings, the nurse should be prepared totahswsihstawt aict ion? a. Throat culture b. Nasal pharynx washing c. Administration of corticosteroids d. Emergency intubation ANS: D Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. Nasotracheal intubation or tracheostomy is usually considered for a child with epiglottitis with severe respiratory distress. The throat should not be inspected because airway obstruction can occur, and steroids would not be done first when the child is in severe respiratory distress. DIF: Cognitive Level: Applying REF: MCS: 1185 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 46. A 3-year-old child woke up in the middle of the night with a croupy cough and inspiratory stridor. The parents bring the child to the emergency department, but by the time they arrive, the cough is gone, and the stridor has resolved. What can the nurse teach the parents with regard to this type of croup? a. A bath in tepid water can help resolve this type of croup. b. Tylenol can help to relieve the cough and stridor. c. A cool mist vaporizer at the bedside can help prevent this type of croup. d. Antibiotics need to be given to reduce the inflammation. ANS: C Acute spasmodic laryngitis (spasmodic croup, midnight croup, or twilight croup) is distinct from laryngitis and LTB and characterized by paroxysmal attacks of laryngeal obstruction that occur chiefly at night. The child goes to bed well or with some mild respiratory symptoms but awakens suddenly with characteristic barking; a metallic cough; hoarseness; noisy inspirations; and restlessness. However, there is no fever, and the episode subsides in a few hours. Children with spasmodic croup are managed at home. Cool mist is recommended for the childs room. A tepid water bath will not help, but steam provided by hot water may relieve the laryngeal spasm. The child will not need Tylenol, and antibiotics are not given for this type of croup. DIF: Cognitive Level: Applying REF: MCS: 1174 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 47. A 3-month-old infant is admitted to the ipaetdric un it for treatment of hbirolnitcis. T he infants vital signs are T, 101.6 F; P, 106 beats/min apical; and R, 70 breaths/min. The infant is irritable and fussy and coughs frequently. IV fluids are given via a peripheral venipuncture. Fluids by mouth were initially contraindicated for what reason? a. Tachypnea b. Paroxysmal cough c. Irritability d. Fever ANS: A Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue. Therefore, IV fluids are prleftehrereadcuutnetsi tage of bronchiolitis has passed. Infants with bronchiolitis may have paroxysmal coughing, but fluids by mouth would not be contraindicated. Irritability or fever would not be reasons for fluids by mouth to be contraindicated. DIF: Cognitive Level: Applying REF: MCS: 1189 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 48. A child is in the hospital for cystic fibrosis. What health care providers prescription should the nurse clarify before implementing? a. Dornase alfa (Pulmozyme) nebulizer treatment bid b. Pancreatic enzymes every 6 hours c. Vitamin A, D, E, and K supplements daily d. Proventil (albuterol) nebulizer treatments tid ANS: B The principal treatment for pancreatic insufficiency that occurs in cystic fibrosis is replacement of pancreatic enzymes, which are administered with meals and snacks to ensure that digestive enzymes are mixed with food in the duodenum. The enzymes should not be given every 6 hours, so this sldhobue clarified before implementing this prescription. Dornase alfa (Pulmozyme) is given by nebulizer to decrease the viscosity of secretions, vitamin supplements are given daily, and Proventil nebulizer treatments are given to open the bronchi for easier expectoration. DIF: Cognitive Level: Applying REF: MCS: 1235 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 49. A 6-year-old child is in the hospital for status asthmaticus. Nursing care during this acute period includes which prescribed interventions? a. Prednisolone (Pediapred) PO every day, IV fluids, cromolyn (Intal) inhaler bid b. Salmeterol (Serevent) PO bid, vital signs every 4 hours, spot check pulse oximetry c. Triamcinolone (Azmacort) inhaler bid, continuous pulse oximetry, vital signs once a shift d. Methylprednisolone (Solumedrol) IV every 12 hours, continuous pulse oximetry, albuterol nebulizer treatments every 4 hours and prn ANS: D The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. A systemic corticosteroid (oral, IV, or IM) may also be given to decrease the effects of inflammation. Inhaled aerosolized short-acting 2- agonists are recommended for all patients. Therefore, Solumedrol per IV, continuous pulse oximetry, and albuterol nebulizer treatments are the expected prescribed treatments. Oral medications would not be used during the acute stage of status asthmaticus. Vital signs once a shift and spot pulse oximetry checks would not be often enough. DIF: Cognitive Level: Applying REF: MCS: 1225 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 50. In providing nourishment for a child with cystic fibrosis (CF), what factors should the nurse keep in mind? a. Fats and proteins must be greatly curtailed. b. Most fruits and vegetables are not well tolerated. c. Diet should be high in calories, proteins, and unrestricted fats. d. Diet should be low fat but high in calories and proteins. ANS: C Children with CF require a well-balanced, high-protein, high-caloric diet, with sutnrirceted f at (because of the impaired intestinal absorption). DIF: Cognitive Level: Analyzing REF: MCS: 1223 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 51. A quantitative sweat chloride test has been done on an 8-month-old child. What value should be indicative of cystic fibrosis (CF)? a. Less than 18 mEq/L b. 18 to 40 mEq/L c. 40 to 60 mEq/L d. Greater than 60 mEq/L ANS: D Normally sweat chloride content is less than 40 mEq/L, with a mean of 18 mEq/L. A chloride concentration greater than 60 mEq/L is diagnostic of CF; in infants younger than 3 months, a sweat chloride concentration greater than 40 mEq/L is highly suggestive of CF. DIF: Cognitive Level: Analyzing REF: MCS: 1237 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 52. A preschool child has asthma, and a goal is to extend expiratory time and increase expiratory effectiveness. tWahctaion should the nurse implement to meet this goal? a. Encourage increased fluid intake. b. Recommend increased use of a budesonide (Pulmicort) inhaler. c. Administer an antitussive to suppress coughing. d. Encourage the child to blow a pinwheel every 6 hours while awake. ANS: D Play techniques that can be used for younger children to extend their expiratory time and increase expiratory pressure include blowing cotton balls or a ping-pong ball on a table, blowing a pinwheel, blowing bubbles, or preventing a tissue from falling by blowing it against the wall. Increased fluids, increased use of a Pulmicort inhaler, oressuspinpgr expiratory effectiveness. DIF: Cognitive Level: Applying REF: MCS: 1233 a cough will not increase TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 53. A school-age child has asthma. The nurse should teach the child that if a peak expiratory flow rate is in the yellow zone, this means that the asthma control is what? a. 80% of a personal best, and the routine treatment plan can be followed. b. 50% to 79% of a personal best and needs an increase in the usual therapy. c. 50 % of a personal best and needs immediate emergency bronchodilators. d. Less than 50% of a personal best and needs immediate hospitalization. ANS: B The interpretation of a peak expiratory flow rate that is yellow (50%79% of personal best) signals caution. Asthma is not well controlled. An acute exacerbation may be present. Maintenance therapy may need tonbcereiased. Call the practitioner if the lcdhistays in this zone. DIF: Cognitive Level: Applying REF: MCS: 1220 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 54. A family requires home care teaching with regard toepnrteavtive measures to use at home to avoid an asthmatic episode. What strategy should the nurse teach? a. Use a humidifier in the childs room. b. Launder bedding daily in cold water. c. Replace wood flooring with carpet. d. Use an indoor air purifier with HEPA filter. ANS: D Allergen control includes use of an indoor air purifier with HEPA filter. Humidity should be kept low, bedding laundered in hot water once a week, and carpet replaced with wood floors. DIF: Cognitive Level: Applying REF: MCS: 1222 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 55. A school-age child with cystic fibrosis takes four enczaypmsules with cmheialdlsi.sThe having four or five bowel movements per day. The nurses action in regard to the pancreatic enzymes is based on the knowledge that the dosage is what? a. Adequate b. Adequate but should be taken between meals c. Needs to be increased to increase the number of bowel movements per day d. Needs to be increased to decrease the number of bowel movements per day ANS: D The amount of enzyme is adjusted to achieve normal growth and a decrease in the number of stools to one or two per day. DIF: Cognitive Level: Applying REF: MCS: 1236 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 56. A term infant is delivered, and oberef delivery, the medical team was antoatified th congenital diaphragmatic hernia (CDH) was diagnosed on ultrasonography. What should be done immediately at birth pifirraetsory d istress dis?note a. Give oxygen. b. Suction the infant. c. Intubate the infant. d. Ventilate the infant with a bag and mask. ANS: C Many infants with a CDH require immediate respiratory assistance, which includes endotracheal intubation and GI decompression with a double-lumen catheter to prevent further respiratory compromise. At birth, bag and mask ventilation is contraindicated to prevent air from entering the stomach and especially the intestines, further compromising pulmonary function. Oxygen and suctioning may be used for mild respiratory distress. DIF: Cognitive Level: Analyzing REF: MCS: 1211 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 57. A child has a streptococcal throat infection and is being treated with antibiotics. What should the nurse teach the parents to prevent infection of others? a. The child can return to school immediately. b. The organism cannot be transmitted through contact. c. The child can return to school after taking antibiotics for 24 hours. d. The organism can only be transmitted if someone uses a personal item of the sick child. ANS: C Children with streptococcal infection are noninfectious to others 24 hours after initiation of antibiotic therapy. It is generally recommended that children not return to school or daycare until they have been taking antibiotics for a full 24-hour period. The organism is spread by close contact with affected personsdirect projection of largetes dorropl secretions containing the organism. DIF: Cognitive Level: Applying REF: MCS: 1173 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safe and Effective Care Environment physical transfer of respiratory 58. What medication is contraindicated in children post tonsillectomy and adenoidectomy? a. Codeine b. Ondansetron (Zofran) b. Amoxil (amoxicillin) c. Acetaminophen (Tylenol) ANS: A Codeine is contraindicated in pediatric patients after tonsillectomy and adenoidectomy. In 2012, the Food and Drug Administration issued a Drug Safety Communication that codeine use in certain children after tonsillectomy or adenoidectomy may lead to rare but life-threatening adverse events or death. Zofran, amoxicillin, and Tylenol are not contraindicated after tonsillectomy and adenoidectomy. DIF: Cognitive Level: Understanding REF: MCS: 1175 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is preparing a staff education program about pediatric asthma. What concepts should the nurse include when discussing the asthma severity classification system? (Select all that apply.) a. Children with mild persistent asthma have nighttime signs or symptoms less than two times a month. b. Children with moderate persistent asthma use a short-acting -agonist more than two times per week. c. Children with severe persistent asthma have a peak expiratory flow (PEF) of 60% to 80% of predicted value. d. Children with mild persistent asthma have signs or symptoms more than two times per week. e. Children with moderate persistent asthma have some limitations with normal activity. f. Children with severe persistent asthma have frequent nighttime signs or symptoms. ANS: D, E, F Children with mild persistent asthma have signs or symptoms more than two times per week and nighttime signs or symptoms three or four times per month. Children with moderate persistent asthma have some limitations with normal activity and need to use a short-acting -agonist for sign or symptom control daily. Children with severe persistent asthma have frequent nighttime signs or symptoms and have a PEF of less than 60%. DIF: Cognitive Level: Analyzing REF: MCS: 1233 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 2. The nurse is caring for a newborn with suspected congenital diaphragmatic hernia. What of the following findings would the nurse expect to observe? (Select all that apply.) a. Loud, harsh murmur b. Scaphoid abdomen c. Poor peripheral pulses d. Mediastinal shift e. Inguinal swelling f. Moderate respiratory distress ANS: B, D, F Clinical manifestations of a congenital diaphragmatic hernia include a scaphoid abdomen, a mediastinal shift, and moderate to severe respiratory distress. The infant would not have a harsh, loud murmur or poor peripheral pulses. Inguinal swelling is indicative of an inguinal hernia. DIF: Cognitive Level: Applying REF: MCS: 1210 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 3. What interventions can the nurse teach parents to do to ease respiratory efforts for a child with a mild preirsatory tract infection? (Select all that apply.) a. Cool mist b. Warm mist c. Steam vaporizer d. Keep child in a flat, quiet position e. Run a shower of hot water to produce steam ANS: A, B, C, E Warm or cool mist is a common therapeutic measure for tsoymaptic relief of respiratory discomfort. The moisture soothes inflamed membranes and is beneficial when there is hoarseness or laryngeal involvement. A time-honored method of producing steam is the shower. Running a shower of hot water into the empty bathtub or open shower stall with the bathroom door closed produces a quick source of steam. Keeping a child in this environment for 10 to 15 minutes may help ease respiratory efforts. A small child can sit on the lap of a parent or other adult. The child should be quiet but upright, not flat. The use of steam vaporizers in the home is often discouraged because of the hazards related to their use and limited evidence to support their efficacy. DIF: Cognitive Level: Applying REF: MCS: 1165 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 4. A tonsillectomy or adenoidectomy is contraindicated in what conditions? (Select all that apply.) a. Cleft palate b. Seizure disorders c. Blood dyscrasias d. Sickle cell disease e. Acute infection at the time of surgery ANS: A, C, E Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate because both tonsils help minimize escape of air during speech, (2) acute infections at the time of surgery because the locally inflamed tissues increase the risk of bleeding, and (3) uncontrolled systemic diseases or blood dyscrasias. Tonsillectomy or adenoidectomy is not contraindicated in sickle cell disease or seizure disorders. DIF: Cognitive Level: Applying REF: MCS: 1174 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. The clinic nurse is administering influenza vaccinations. Which children should not receive the live attenuated influenza vaccine (LAIV)? (thSaeltect all apply.) a. A child with asthma b. A child with diabetes c. A child with hemophilia A d. A child with cancer receiving chemotherapy e. A child with gastroesophageal reflux disease ANS: A, B, D The live attenuated influenza vaccine (LAIV) is an acceptable alternative to the IM vaccine (IIV) for ages 2 to 49 sy.eIar t is a live vaccine administered vainasal spray. Several groups are excluded from receiving it, including children with a chronic heart or lung disease (asthma or reactive airways disease), diabetes, or kidney failure; children who are immunocompromised or receiving immunosuppressants; children younger than 5 years of age with a history of recurrent wheezing; children receiving aspirin; patients who are pregnant; children who have a severe allergy to chicken eggs or who are allergic to any of the nasal spray vaccine components; or children hwiat hitoryso f Guillain-Barr Syndrome after a previous dose. A child with hemophilia A or gastroesophageal reflux disease would not mbemiunocompromised so ty cahnereceive the LAIV. DIF: Cognitive Level: Applying REF: MCS: 1177 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. The nurse is preparing to admit a 7-year-old child with acute laryngotracheobronchitis (LTB). What clinical manifestations should the nurse expect tovoeb?se(Srelect all that apply.) a. Dysphagia b. Brassy cough c. Low-grade fever d. Toxic appearance e. Slowly progressive ANS: B, C, E Clinical manifestations of LTB include a brassy cough, low-grade fever, and slow progression. Dysphagia and a toxic appearance are characteristics of acute epiglottitis. DIF: Cognitive Level: Applying REF: MCS: 1184 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. The nurse is preparing to admit a 3-year-old child with acute spasmodic laryngitis. What clinical features of hepatitis B should tnhuer se recognize? (Select all that apply.) a. High fever b. Croupy cough c. Tendency to recur d. Purulent secretions e. Occurs sudden, often at night ANS: B, C, E Clinical features of acute spasmodic laryngitis include a croupy cough, a tendency to recur, and occurring sudden, often at night. High fever is a feature of acute epiglottitis and purulent secretions are seen with acute tracheitis. DIF: Cognitive Level: Analyzing REF: MCS: 1184 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. A child is diagnosed with active pulmonary tuberculosis. What medications does the nurse anticipate to be prescribed for the first 2 months? (Select all that apply.) a. Isoniazid (INH) b. Cefuroxime (Ceftin) c. Rifampin (Rifadin) d. Pyrazinamide (PZA) e. Ethambutol (Myambutol) ANS: A, C, D, E For the child with clinically active pulmonary raanpduelmxtona ry TB, the goal is to achieve sterilization of the tuberculous lesion. The American Academy of Pediatrics (2012) recommends a 6-month regimen consisting of INH, rifampin, ethambutol, and PZA given daily or twice weekly for the first 2 months followed by INH and rifampin given two or three times a week by DOT for the remaining 4 months (Mycobacterium tuberculosis). Cefuroxime is not part of the regimen. DIF: Cognitive Level: Analyzing REF: MCS: 1200 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. The nurse is interpreting a tuberculin skin test. If the nurse finds a result of an induration 5 mm or larger, in which child should the nurse document this finding as positive? (Select all that apply.) a. A child with diabetes mellitus b. A child younger than 4 years of age c. A child receiving immunosuppressive therapy d. A child with a human immunodeficiency virus (HIV) infection e. A child living in close contact with a known contagious case of tuberculosis ANS: C, D, E A tuberculin skin test with an induration of 5 mm or larger is considered to be positive if the child is receiving immunosuppressive therapy, has an HIV infection, or is living in close contact with a known contagious case of tuberculosis. The test would be considered positive lidn a chi who has diabetes mellitus or is younger than 4 years of age if the tuberculin skin test had an induration of 10 mm or larger. DIF: Cognitive Level: Applying REF: MCS: 1198 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 10. The nurse is preparing to admit a 7-year-old child with pulmonary edema. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Fever b. Bradycardia c. Diaphoresis d. Pink frothy sputum e. Respiratory crackles ANS: C, D, E Clinical manifestations of pulmonary edema include diaphoresis, pink frothy sputum, and respiratory crackles. Fever or bradycardia are not manifestations of pulmonary edema. DIF: Cognitive Level: Applying REF: MCS: 1204 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity COMPLETION 1. The nurse is calculating the amount of expected urinary output for a 24-hour period on a child with bacterial pneumonia who weighs 22 lb. The nurse recognizes the formula to be used is 1 ml/kg/hr. What is the expected 24-hour urinary output for this child in imliitlelrs? R ecord your answer below in a whole number. ANS: 240 Perform the calculation. 22/2.2 = 10 kg 10 1 24 = 240 ml DIF: Cognitive Level: Understanding REF: MCS: 1192 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 2. The nurse is calculating the amount of expected urinary output for a 24-hour period on a child with laryngotracheobronchitis who weighs 33 lb. The nurse recognizes the formula to be used is 1 ml/kg/hr. What is the expected 24-hour urinary output for this child in milliliters? Record your answer below in a whole number. ANS: 360 Perform the calculation. 33/2.2 = 15 kg 15 1 24 = 360 ml Chapter 27.The Child with Cardiovascular Dysfunction MULTIPLE CHOICE 1. What term is defined as the volume of blood ejected by the heart in 1 minute? a. Afterload b. Cardiac cycle c. Stroke volume d. Cardiac output ANS: D Cardiac output is defined as the volume of blood ejected by the heart in 1 minute. Cardiac output = Heart rate x Stroke volume. Afterload is the resistance against which the ventricles must pump when ejecting blood (ventricular ejection). A ciaacrdcycle is the sequentia l contraction and relaxation of both the atria and ventricles. Stroke volume is the amount of blood ejected by the heart in any one contraction. DIF: Cognitive Level: Understanding REF: MCS: 1254 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiological Integrity 2. A chest radiography examination is ordered for a child with suspected cardiac problems. The childs parent asks the nurse, What will the x-ray show about the heart? The nurses response should be based on knowledge that the radiograph provides which information? a. Shows bones of the chest but not the heart b. Evaluates the vascular anatomy outside of the heart c. Shows a graphic measure of electrical activity of the heart d. Supplies information on heart size and pulmonary blood flow patterns ANS: D Chest radiographs provide information on the size of the heart and pulmonary blood flow patterns. The bones of the chest are visible on chest radiographs, but the heart and blood vessels are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography. DIF: Cognitive Level: Understanding REF: MCS: 1256 TOP: NursoicnegssP:rAssessment lMieSnCt : C Needs: Physiological Integrity 3. A 6-year-old child is scheduled for a cardiac catheterization. What consideration is most important in planning preoperative teaching? a. Preoperative teaching should be directed at his parents because he is too young to understand. b. Preoperative teaching should be adapted to his level of development so that he can understand. c. Preoperative teaching should be done several days before the procedure so he will be prepared. d. Preoperative teaching should provide details about the actual procedures so he will know what to expect. ANS: B Preoperative teaching should always be directed to the childs stage of development. The caregivers also benefit from these explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group will not understand in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization. DIF: Cognitive Level: Applying REF: MCS: 1259 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 4. After returning from cardiac catheterization, the nurse monitors the iclhds heart rate should be counted for how many seconds? a. 15 lvistiagns. T he b. 30 c. 60 d. 120 ANS: C The heart rate is counted for a full minute to determine whether arrhythmias or bradycardia is present. Fifteen to 3ar0 seconds assess heart rate and rhythm. e too short for taeccaussraessment. S ixty seconds is sufficient to DIF: Cognitive Level: Applying REF: MCS: 1260 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. After returning from cardiac catheterization, the nurse determines that the epudls catheter insertion site is weaker. How should the nurse respond? a. Elevate the affected extremity. b. Notify the practitioner of the observation. c. Record data on the assessment flow record. d. Apply warm compresses to the insertion site. ANS: C istal to the The pulse distal to the catheterization site may be weaker for tfhierst f ew hours after catheterization but should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are not indicated. DIF: Cognitive Level: Applying REF: MCS: 1260 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is too wet. The nurse finds the bandage and bed soaked with blood. What nursing action is most appropriate to institute initially? a. Notify the physician. b. Place the child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above the catheterization site. ANS: D When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure on the vessel puncture. The physician can ibfeiendo, t and gaenwewithbamnodrae pressure can be applied afterepsrsure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. Trendelenburg positioning would not be a helpful intervention. It would increase the drainage from the lower extremities. DIF: Cognitive Level: Analyzing REF: MCS: 1259 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. What statement best identifies the cause of heart failure (HF)? a. Disease related to cardiac defects b. Consequence of an underlying cardiac defect c. Inherited disorder associated with a variety of defects d. Result of diminished workload imposed on an abnormal myocardium ANS: B HF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the bodys metabolic demands. HF is not a disease but rather a result of the inability of the heart to pump efficiently. HF is not inherited. HF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles. DIF: Cognitive Level: Understanding REF: MCS: 1262 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this t?ime a. Administer oxygen. b. Record data on the nurses notes. c. Report data to the practitioner. d. Place the child in the high Fowler position. ANS: C One of tehaerliest signs of HF is tachycardia (sleeping heart rate s>/1m6i0n)beat as a direct result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible HF. Although oxygen or a semiupright position may be indicated, the first action is to report the data to the practitioner. DIF: Cognitive Level: Analyzing REF: MCS: 1267 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. What drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Furosemide (Lasix) b. Captopril (Capoten) c. Chlorothiazide (Diuril) d. Spironolactone (Aldactone) ANS: B Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Chlorothiazide works on the distal tubules. Spironolactone blocks the action of aldosterone and is a potassium-sparing diuretic. DIF: Cognitive Level: Understanding REF: MCS: 1305 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 10. A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate? a. 60 beats/min b. 90 beats/min c. 100 beats/min d. 120 beats/min ANS: B If a 1-minute apical pulse is less than 90 beats/min for an infant or young child, the digoxin is withheld. Sixty beats/min is the cut-off for holding the digoxin dose in ta.nOandeulhundred to 120 beats/min is an acceptable pulse rate for the administration of digoxin. DIF: Cognitive Level: Understanding REF: MCS: 1313 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. What ncliifneisctatlimonais a common sign of digoxin toxicity? a. Seizures b. Vomiting c. Bradypnea d. Tachycardia ANS: B Vomiting is a common sign of digoxin toxicity and is often unrelated to feedings. Seizures are not associated with digoxin toxicity. The child lwl ihave a slower (not faster) heart rate but not a slower respiratory rate. DIF: Cognitive Level: Understanding REF: MCS: 1266 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. The parents of a young child with heart failure (HF) tell the nurse that tyhaer e nervous about giving digoxin. The nurses response should be based on which knowledge? a. It is a safe, frequently used drug. b. Parents lack the expertise necessary to administer digoxin. c. It is difficult to either overmedicate or undermedicate with digoxin. d. Parents need to learn specific, important guidelines for administration of digoxin. ANS: D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Parents may lack the expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely. DIF: Cognitive Level: Analyzing REF: MCS: 1267 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 13. What nutritional component should be taelred in the infant with heart failure (HF)? a. Decrease in fats b. Increase in fluids c. Decrease in protein d. Increase inocraiel s ANS: D Infants with HF haavgereater m etabolic rate because of poor accarfduinction and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and rineacsed f at tolfitaactie the childs intake of sufficient ocariles. F luids must be carefully monitored because of the HF. DIF: Cognitive Level: Analyzing REF: MCS: 1268 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 14. Decreasing the demands on the ahe rt is a priority in care for the infant with rhtefaailure (HF). In evaluating the infants status, which finding is indicative of achieving this goal? a. Irritability when awake b. Capillary refill of more than 5 seconds c. Appropriate weight gain for age d. Positioned in high Fowler position to maintain oxygen saturation at 90% ANS: C Appropriate weight gain nfofranatn i is indicative of successful feeding and a reduction in caloric loss secondary to tHhFe. I rritability is a symptom of cHhFil.dTahleso us es additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation. DIF: Cognitive Level: Analyzing REF: MCS: 1268 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 15. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure. ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents. DIF: Cognitive Level: Analyzing REF: MCS: 1273 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16. A 3-month-old infant has a hypercyanotic spell. What should be the nurses first action? a. Assess for neurologic defects. b. Prepare the family for imminent death. c. Begin cardiopulmonary resuscitation. d. Place the child in the kneechest position. ANS: D The first action is to place the infant in the kneechest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell. DIF: Cognitive Level: Applying REF: MCS: 1273 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 17. A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can urelst in w hich condition? a. Cyanosis b. Heart failure c. Decreased pulmonary blood flow d. Bounding pulses in upper extremities ANS: B As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for heart failure. Cyanosis usuallycoucrs in de fects with decreased pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the aorta. DIF: Cognitive Level: Applying REF: MCS: 1262 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 18. What blood flow pattern occurs in a ventricular septal defect? a. Mixed blood flow b. Increased pulmonary blood flow c. Decreased pulmonary blood flow d. Obstruction to blood flow from ventricles ANS: B The opening in the septal wall allows for blood to flow from the higher pressure left ventricle into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect. DIF: Cognitive Level: Understanding REF: MCS: 1276 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 19. The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which complication? a. Hypoxemia b. Right-to-left shunt of blood c. Decreased workload on the left side of the heart d. Pulmonary vascular congestion ANS: D In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein, resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion. Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased workload on the left side of the heart with a PDA. DIF: Cognitive Level: Applying REF: MCS: 1278 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 20. What cardiovascular defect results in obstruction to blood flow? a. Aortic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries ANS: A Aortic stenosis is a narrowing or stricture of the aortic valve,scisatuasnicneg troe blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. Tricuspid atresia results in decreased pulmonaryobwlo.oTd fl he atrial septal defect results in increased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow. DIF: Cognitive Level: Understanding REF: MCS: 1279 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 21. What structural defects constitute tetralogy of oFta?ll a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy ANS: A Tetralogy of Fallot has these four acchtaerristics: pul monary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. DIF: Cognitive Level: Understanding REF: MCS: 1280 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. The parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. How should the nurse reply to this concern? a. The parents should meet all the childs needs. b. The child needs opportunities to play with peers. c. Constant parental supervision is needed to avoid overexertion. d. The child needs to understand that peers activities are too strenuous. ANS: B The child needs opportunities for social development. Children are able to regulate and limit their activities based on gthyeir ener level. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. DIF: Cognitive Level: Analyzing REF: MCS: 1285 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 23. What preparation should the nurse consider when educating a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let the child hear the sounds of a cardiac monitor, including alarms. c. Explain that an endotracheal tube will not be needed if the surgery goes well. d. Discussion of postoperative discomfort and interventions is not necessary before the procedure. ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The family and child should make the decision about a tour of the unit if it is an option. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, endotracheal tube, expected discomfort, and management strategies. DIF: Cognitive Level: Applying REF: MCS: 1286 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 24. Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4 C (101.1 F). What action should the nurse perform? a. Report findings to the practitioner. b. Apply a hypothermia blanket. c. Keep the child warm with blankets. d. Record the temperature on the assessment flow sheet. ANS: A In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues after this period, it sist lmikoely a sign of an infection, and immediate investigation is indicated. A hypothermia blanket is not indicated for this level of temperature. Blankets should be removed from the child to keep the temperature from increasing. The temperature should be recorded, but the practitioner must be notified for evaluation. DIF: Cognitive Level: Applying REF: MCS: 1289 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. What nursing consideration is important when suctioning a young child who has had heart surgery? a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Expect symptoms of respiratory distress when suctioning. d. Administer supplemental oxygen before and after suctioning. ANS: D When suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated and very carefully to avoid vagal stimulation. The child should be suctioned for no more than 5 seconds at a time. Symptoms of respiratory distress are avoided by using appropriate technique. DIF: Cognitive Level: Applying REF: MCS: 1289 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 26. The nurse notices that a child is increasingly apprehensive and has tachycardia after heart surgery. The chest tube drainage is now 8 ml/kg/hr. What should be the nurses initial intervention? a. Apply warming blankets. b. Notify the practitioner of these findings. c. Give additional pain medication per protocol. d. Encourage child to cough, turn, and deep breathe. ANS: B The practitioner is notified immediately. Increases of chest tube drainage to more than 3 ml/kg/hr for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative hemorrhage. Increased chest tube drainage with apprehensiveness and tachycardia may indicate cardiac tamponadeblood or fluid in the pericardial space constricting the heartwhich is a life- threatening complication. Warming blankets are not indicated at this time. Additional pain medication ncabnebe give fore the practitioner drains the fluid, but the incoattiifon is the tfirs action. Encouraging the child to cough, turn, and deep breathe should be deferred until after evaluation by the practitioner. DIF: Cognitive Level: Applying REF: MCS: 1291 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 27. A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38 C (100.4 F), and now her muscles and joints ache. Based on this information, how should the nurse advise the mother? a. Immediately bring the child to the clinic for evaluation. b. Come to the clinic next week on a scheduled appointment. c. Treat the signs and symptoms with acetaminophen and fluids because it is most likely a viral illness. d. Recognize that the child is trying to manipulate the parent by complaining of vague symptoms. ANS: A These are the insidious symptoms of bacterial endocarditis. Because the child is isnk a high-ri group for this disorder (VSD reirp),aimediamte e valuation and treatment are indicated to prevent cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated in approximately 80% of the cases. The childs complaints should not ibsemdissed. The low- grade fever is not a symptom that the child can fabricate. DIF: Cognitive Level: Applying REF: MCS: 1277 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 28. What primary nursing intervention should be implemented to prevent bacterial endocarditis? a. Counsel parents of high-risk children. b. Institute measures to prevent dental procedures. c. Encourage restricted mobility in susceptible children. d. Observe children for complications, such as embolism and heart failure. ANS: A The objective of nursing care is to counsel the parents of high-risk children about the need for both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The childs dentist should be aware of the childs cardiac condition. Dental procedures should be done to maintain a high level lofheoaralth. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior. DIF: Cognitive Level: Applying REF: MCS: 1273 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 29. What sign/symptom is a major ncliical m anifestation of rheumatic fever (RF)? a. Fever b. Polyarthritis c. Osler nodes d. Janeway spots ANS: B Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation. The affected joints will change every 1 or 2 days. The large joints are primarilyeacftfed. Fever is considered a minor fmeastnaition of RF. Osler nodes and Janeway spots are characteristic of bacterial endocarditis. DIF: Cognitive Level: Analyzing REF: MCS: 1296 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 30. What action by the hscool nurse is im portant in the vperention of rheumatic fever (RF)? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts. ANS: C Nurses have a role in prevention, primarily in screening school-age children for sore throats caused by group A streptococci. They can actively participate in throat culture screening or refer children with possible streptococcal sore throats for testing. Routine cholesterol escnriengs and blood pressure screenings do not facilitate the recognition and treatment of group A hemolytic streptococci. Sicayllate s should be avoided routinely because of the risk of Rsyeynedrome after viral illnesses. DIF: Cognitive Level: Applying REF: MCS: 1298 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 31. When caring for the child with Kawasaki disease, what should the nurse know to provide safe and effective care? a. Aspirin is contraindicated. b. The principal area of involvement is the joints. c. The childs fever is usually responsive to antibiotics within 48 hours. d. Therapeutic management includes administration of gamma globulin and salicylates. ANS: D High-dose intravenous gamma globulin and salicylate therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is responsive to anti-inflammatory doses of aspirin and antipyretics. DIF: Cognitive Level: Applying REF: MCS: 1298 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 32. Nursing care of the child with Kawasaki disease is challenging because of which occurrence? a. The childs irritability b. Predictable disease course c. Complex antibiotic therapy d. The childs ongoing requests for food ANS: A Patient irritability is a hallmark of Kawasaki disease and is the most challenging problem. A quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should be offered to prevent dehydration. DIF: Cognitive Level: Understanding REF: MCS: 1298 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 33. The diagnosis of hypertension depends on accurate assessment of blood pressure (BP). What is the appropriate technique to measure a childs BP? a. Assess BP while the child is standing. b. Compare left arm with left leg BP readings. c. Use a narrow cuff to ensure that the readings are correct. d. Measure BP with the child in the sitting position on three separate occasions. ANS: D The diagnosis of hypertension is made after the BP is elevated on three separate occasions. Take the BP in a quiet area with the appropriate size cuff and the child sitting. Although left arm and left leg BP readings may be compared, it is not the procedure to diagnose hypertension. The appropriate size cuff is indicated. The most common cause of inaccurate readings is the use of a cuff that is too small. DIF: Cognitive Level: Applying REF: MCS: 1303 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 34. What type of drug reduces hypertension by interfering with the production of angiotensin II? a. Diuretics b. Vasodilators c. Beta-blockers d. Angiotensin-converting enzyme (ACE) inhibitors ANS: D ACE inhibitors act by interfering with the production of angiotensin II,iwchhis anpt ot e vasoconstrictor. Diuretics lower blood pressure by increasing fluid output. Vasodilators act on the vascular smooth muscle. By causing arterial dilation, blood pressure is lowered. Beta- blockers interfere with beta stimulation and depress renin output. DIF: Cognitive Level: Understanding REF: MCS: 1307 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 35. Selective cholesterol screening is recommended for children older than the age of 2syear with which risk factor? a. Body mass index (BMI) = 95th percentile b. Blood pressure = 50th percentile c. Parent with a blood cholesterol level of 200 mg/dl d. Recently diagnosed cardiovascular disease in a 75-year-old grandparent ANS: A Obesity is an indication for cholesterol screening in children. A BMI in the 95th percentile or higher is considered obese. Children who are hypertensive meet the criteria for screening, but blood pressure in the 50th percentile is within the normal range. A parent or grandparent with a cholesterol level of 240 mg/dl or higher places the child at risk. Early cardiovascular disease in a first- or second-degree relative is a risk factor. Age 75 years is not considered early. DIF: Cognitive Level: Applying REF: MCS: 1303 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 36. What condition is the leading cause of death after heart transplantation? a. Infection b. Rejection c. Cardiomyopathy d. Heart failure ANS: B The posttransplant course is complex. The leading cause of death after cdaiarc transplant is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the aintidoincs for cardiac transplant. Heart failure is not a leading cause of death. DIF: Cognitive Level: Understanding REF: MCS: 1316 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 37. The nurse is giving discharge instructions to the parent of a 6-year-old child who had a cardiac catheterization 4 hours ago. What statement by the parent indicates a correct understanding of the teaching? a. My child should not attend school for the next 5 days. b. I should change the bandage every day for the next 2 days. c. My child can take a tub bath but should avoid taking a shower for the next 4 days. d. I should expect the site to be red and swollen for the next 3 days. ANS: B Discharge instructions for a parent of a child who recently had a cardiac catheterization should include changing the bandage every day for the next 2 days. The child should avoid strenuous exercise but can go back to school. The child should avoid a tub bath, but an older child could take a shower the first day after the catheterization. The site should not have swelling or redness; if there is, it should be reported to the health care practitioner. DIF: Cognitive Level: Analyzing REF: MCS: 1260 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 38. A child with heart failure is on Lanoxin (digoxin). The laboratory value a nurse must closely monitor is which? a. Serum sodium b. Serum potassium c. Serum glucose d. Serum chloride ANS: B A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin toxicity. Increased serum potassium levels diminish digoxins effect. Therefore, serum potassium levels (normal range, 3.55.5 mmol/L) must be carefully monitored. DIF: Cognitive Level: Applying REF: MCS: 1267 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Safe and Effective Care Environment 39. An infant has tetralogy of Fallot. In reviewing the record, what laboratory result should the nurse expect to be documented? a. Leukopenia b. Polycythemia c. Anemia d. Increased platelet level ANS: B Persistent hypoxemia that occurs with rteatlogy of Fallot stimulates erythropoiesis, which results in polycythemia, an increased number of red blood cells. DIF: Cognitive Level: Analyzing REF: MCS: 1267 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 40. What child has a cyanotic congenital heart defect? a. An infant with patent ductus arteriosus b. A 1-year-old infant with atrial septal defect c. A 2-month-old infant with tetralogy of Fallot d. A 6-month-old infant with repaired ventricular septal defect ANS: C Tetralogy of Fallot is a cyanotic congenital heart defect.tPenat ductus arteriosus, atrial septal defect, and ventricular septal defect are acyanotic congenital heart defects. DIF: Cognitive Level: Analyzing REF: MCS: 1261 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 41. The nurse is teaching parents about administering digoxin (Lanoxin). What instructions should the nurse tell the parents? a. If the child vomits, give another dose. b. Give the medication at regular intervals. c. If a dose is missed, give a give an extra dose. d. Give the medication mixed with the childs formula. ANS: B The family should be taught to administer digoxin at regular intervals. If a dose is missed, an extra dose should not be given; the same schedule should be maintained. If the child vomits, do not give a second dose. The drug should not be mixed with foods or other fluids because refusal to consume these would result in inaccurate intake of the drug. DIF: Cognitive Level: Applying REF: MCS: 1265 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 42. Heart failure (HF) is a problem after the child has had a congenital hrtedae fect repaired. The nurse knows a sign of HF is what? a. Wheezing b. Increased blood pressure c. Increased urine output d. Decreased heart rate ANS: A A clinical manifestation of heart failure is wheezing from pulmonary congestion. The blood pressure decreases, urine output decreases, and heart rate increases. DIF: Cognitive Level: Analyzing REF: MCS: 1264 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 43. The health care provider suggests surgery be performed for ventricular septal defect to prevent what complication? a. Pulmonary hypertension b. Right-to-left shunt of blood c. Pulmonary embolism d. Left ventricular hypertrophy ANS: A Congenital heart defects with ta-large lef to-right shunt (e.g., in ventricular septal defect, patent ductus arteriosus, or complete AV canal), which cause increased pulmonary blood flow, may result in pulmonary hypertension. If these defects are not repaired early, the high pulmonary flow will cause changes in the pulmonary artery vessels, and the vessels will lose their elasticity. The blood does not shunt right to left, a pulmonary embolism is not a complication of ventricular septal defect, and the left ventricle does not hypertrophy. DIF: Cognitive Level: Analyzing REF: MCS: 1277 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 44. A 1-year-old has been admitted for complete repair of a tetralogy of Fallot. What assessment finding should the nurse expect to be documented? a. Weight gain b. Pale skin color c. Increasing cyanosis d. Decrease in hemoglobin and hematocrit ANS: C Elective repair of tetralogy of Fallot is usuallyopremrfed in the tfiyrsea r of life. Indications for repair include increasing cyanosis and the development of hypercyanotic spells. The child would not have a weight gain, pale skin color, or decrease in hemoglobin and hematocrit. DIF: Cognitive Level: Analyzing REF: MCS: 1280 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 45. A 6-month-old infant presents to the clinic with failure to thrive, a history of frequent respiratory infections, and increasing exhaustion during feedings. On physical examination, a systolic murmur is detected, no central cyanosis, and chest radiography reveals cardiomegaly. An echocardiogram is done that shows left-to-right shunting. This assessment data is characteristic of what? a. Tetralogy of Fallot b. Coarctation of the aorta c. Pulmonary stenosis d. Ventricular septal defect ANS: D Heart failure is common with rviecnutlar septal defect that causes f ailure to thrive,priersatory infections, and an increase in exhaustion during feedings. There is a characteristic murmur. The other defects do not have left-to-right shunting. DIF: Cognitive Level: Analyzing REF: MCS: 1314 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 46. An infant is diagnosed with transposition of the great vessels. Prostaglandin E1 is given intravenously. The parents ask how long the child will remain on the prostaglandin E1. What is the appropriate response by the nurse? a. Prostaglandin E1 will be given intermittently until corrective surgery is performed. b. Prostaglandin E1 will be given continuously until corrective surgery is performed. c. Prostaglandin E1 will be given continuously throughout the preoperative and postoperative periods until the child is stable. d. Prostaglandin E1 will be given intermittently throughout the preoperative and postoperative periods until the child is stable. ANS: B To provide intracardiac mixing for a child with transposition of the great arteries, intravenous prostaglandin E1 is administered continuously to keep the ductus arteriosus open to temporarily increase blood mixing and provide an oxygen saturation of 75% or to maintain cardiac output until surgery. It is discontinued after surgery. DIF: Cognitive Level: Applying REF: MCS: 1273 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 47. What medication used toattreheart failure (HF) is a d iuretic? a. Captopril (Capten) b. Digoxin (Lanoxin) c. Hydrochlorothiazide (Diuril) d. Carvedilol (Coreg) ANS: C Hydrochlorothiazide is a diuretic. Captopril is an bAiCtoEr, idnihgioxi n is a digital glycoside, and carvedilol is a beta-blocker. DIF: Cognitive Level: Analyzing REF: MCS: 1305 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 48. The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose and draws up 4 ml of the drug. The most appropriate nursing action is which? a. Mix the dose with juice to disguise its taste. b. Do not give the dose; suspect a dosage error. c. Check the heart rate; administer digoxin if the rate is greater than 100 beats/min. d. Check the heart rate; administer digoxin if the rate is greater than 80 beats/min. ANS: B Infants rarely receive more than 1 ml (50 mcg, or 0.05 mg) of digoxin in one dose; a higher dose is an immediate warning of a dosage error. To ensure safety, compare the calculation with that of another staff member before giving digoxin. DIF: Cognitive Level: Applying REF: MCS: 1313 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 49. A 12-year-old child with Down syndrome is admitted to the hospital for surgical correction of a heart defect. The boys mental age is that of a 3-year-old child. The nurse should prepare the child and family for surgery by what method? a. Extend preoperative teaching over several days. b. Explain the surgery to the child and the parents in detail. c. Exclude the child from preoperative teaching; teach only the parents. d. Provide teaching to the parents, keeping the information to the child simple. ANS: D Important factors to consider in planning preparation strategies before cardiac surgery are the childs cognitive developmental level, previous hospital experiences, temperament and coping style, the timing of the preparation, and the involvement of the parents. The teaching should be provided to the parents, keeping the information simple to the child with a mental age of 3 years old. DIF: Cognitive Level: Applying REF: MCS: 1277 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 50. Bacterial infective endocarditis (IE) should be treated with which protocol? a. Oral antibiotics for 6 months b. Oral antibiotics (penicillin) for 10 full days c. IV antibiotics, diuretics, and digoxin d. IV antibiotics (penicillin type) for 2 to 8 weeks ANS: D Treatment for IE includes the administration of high-dose antibiotics given intravenously for 2 to 8 weeks to completely eradicate the infecting microorganism. DIF: Cognitive Level: Understanding REF: MCS: 1295 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 51. A child is recovering from Kawasaki disease (KD). The child should be monitored for which? a. Anemia b. Electrocardiograph (ECG) changes c. Elevated white blood cell count d. Decreased platelets ANS: B The most serious complication of KD is the development of coronary artery aneurysms and the potential for myocardial infarction in children with aneurysm formation. The nurse should monitor any ECG changes. DIF: Cognitive Level: Applying REF: MCS: 1299 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 52. The test that provides the most reliable evidence of recent streptococcal infection is which? a. Throat culture b. Mantoux test c. Antistreptolysin O test d. Elevation of liver enzymes ANS: C Antistreptolysin O (ASLO) titers measure the concentration iobfoadnites formed in the blood against this product. Normally, the titers begin to rise about 7 days after onset of the infection and reach maximum levels in 4 to 6rwefeoerkes, .aTrhiseing titer de monstrated by at least two ASLO tests is the most reliable evidence of recent streptococcal infection. DIF: Cognitive Level: Applying REF: MCS: 1297 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is caring for a child with Kasaawki disease inethacute phase. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Osler nodes b. Cervical lymphadenopathy c. Strawberry tongue d. Chorea e. Erythematous palms f. Polyarthritis ANS: B, C, E Clinical manifestations of Kawasaki disease in the acute phase include cervical lymphadenopathy, a strawberry tongue, and erythematous palms. Oersnl ode s are a clinical manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever. DIF: Cognitive Level: Applying REF: MCS: 1298 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The nurse is caring for a child after cardiac surgery. What interventions should the nurse implement with regard to chest tubes placed to a water-seal drainage system? (Select all that apply.) a. Maintain sterility. b. Check for tube patency. c. Do not interrupt the water-seal drainage system. d. Clamp the chest tube when ambulating the child. e. Measure the drainage by emptying the collection chamber every shift. ANS: A, B, C Nursing considerations with regard to chest tubes attached to a water-seal drainage system include (1) do not interrupt water-seal drainage unless the chest tube is clamped, (2) check for tube patency (fluctuation in the water-seal chamber), and (3) maintain sterility. The echst tube should not be clamped when ambulating the child and the drainage is measured in the collection chamber, not emptied. DIF: Cognitive Level: Applying REF: MCS: 1315 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The nurse is caring for a child with secondary hypertension. What renal disorders are associated with secondary hypertension? (Select all that apply.) a. Renal tumor b. Hydronephrosis c. Vesicoureteral reflux d. Glomerulonephritis e. Urinary tract infection ANS: A, B, D Renal disorders that can cause secondary hypertension include a renal tumor, hydronephrosis, and glomerulonephritis. Vesicoureteral reflux or urinary tract infections do not cause secondary hypertension. DIF: Cognitive Level: Analyzing REF: MCS: 1303 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. The nurse is teaching an adolescent with hypertension foods recommended on the DASH diet. What foods should the nurse include in the teaching session? (Select all that apply.) a. Green beans b. Energy drinks c. Low-fat yogurt d. Chocolate milk e. Whole grain bread ANS: A, C, E The DASH diet provides a lower salt diet that has been associated with improvement in BP and is believed to be beneficial for all patients with hypertension. DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is plentiful in vegetables, fruits, whole grains, and low-fat dairy products and low in sugar and salt. Energy drinks are high in sugar, and chocolate milk is high in fat. DIF: Cognitive Level: Applying REF: MCS: 1304 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. An adolescent is being placed on an ACE inhibitor. What should the nurse inform the adolescent with regard to this mdiecation? (Select all that apply.) a. Stay well hydrated. b. Increase intake of potassium. c. Avoid rapid position changes. d. Take the medication with meals. e. Side effects may include a cough. ANS: A, C, E The adolescent should be instructed to stay well hydrated and avoid rapid position changes and that side effects may include a cough when on ACE inhibitors. ACE inhibitors do not deplete potassium, and they should be taken 1 hour before meals to increase absorption. DIF: Cognitive Level: Applying REF: MCS: 1305 TOP: Integrated oPcress: T eaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. An adolescent is being placed on a beta-blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.) a. Medication may cause fatigue. b. Side effects may include impotence. c. Side effects may include bradycardia. d. Take the medication 1 hour before meals. e. Side effects may include peripheral edema. ANS: A, B, C The adolescent should be instructed that the medication may cause fatigue, impotence, and bradycardia. The medications should be taken with meals and side effects do not include peripheral edema. DIF: Cognitive Level: Applying REF: MCS: 1305 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 7. An adolescent is being placed on a calcium channel blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.) a. The medication may cause fatigue. b. The medication may increase heart rate. c. The medication may cause constipation. d. The medication may cause cold extremities. e. The medication may cause peripheral edema. ANS: B, C, E Calcium channel blockers may cause an increase in heart rate, constipation, and ippehreral edema. Beta-blockers can cause fatigue and cold extremities, but ucamlci not cause these potential side effects. DIF: Cognitive Level: Applying REF: MCS: 1307 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Health P romotion and Maintenance channel blockers do 8. The nurse is teaching an adolescent with elevated triglycerides foods that should be decreased. What foods should the nurse include in the teaching? (Select all that apply.) a. Avocados b. Canola oil c. White flour d. White rice e. Sugary cereals ANS: C, D, E If triglycerides are elevated, dietary recommendations include decreasing the intake of foods high in simple carbohydrates such as white flour, white rice, white bread, white pasta, sugary cereals, juice, and soda. Avocados and canola oil have beneficial effects on HDL, which is the good cholesterol. DIF: Cognitive Level: Applying REF: MCS: 1309 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. What interventions should the nurse anticipate being administered to a child with supraventricular tachycardia (SVT)? a. Bed rest b. Applying ice to the face c. Administration of atropine d. Administration of adenosine (Adenocor) e. Having the child perform a Valsalva maneuver ANS: B, D, E The treatment of SVT depends on the degree of compromise imposed by the dysrhythmia. In some instances, vagal maneuvers, such as applying ice to the face, massaging the carotid artery (on one side of the neck only), or having an older child perform a Valsalva maneuver (e.g., exhaling against a closed glottis, blowing on the thumb as if it were a trumpet for 30 to 60 seconds), can reverse the SVT. When vagal maneuvers fail, adenosine may be used to end the episode of SVT by impairing AV node conduction. IV adenosine is the first-line pharmacologic measure for termination of SVT in infants and children in the emergency setting. Administration of atropine or bed rest will not resolve SVT. DIF: Cognitive Level: Applying REF: MCS: 1311 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity COMPLETION 1. A health care provider prescribes furosemide (Lasix), 10 mg intravenously (IV) now, for a child with heart failure. The medication label states: Furosemide (Lasix) 20 mg/2 ml. The nurse prepares to administer the dose. How many milliliters will the enuprrs dose? Fill in the blank. Record your answer in a whole number. epare toiandismte r the ANS: 1 Follow the formula for dosage calculation. Desired Volume = ml per dose Available 10 mg 2 ml = 2 ml 20 mg DIF: Cognitive Level: Applying REF: MCS: 1266 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 2. A health care provider prescribes hydroxyzine (Atarax), 0.6 mg/kg PO every 4 to 6 hours as needed for pruritus for a child with Kawasaki dmisedaiscea.tTiohne label states: Hydroxyzine 10 mg/5 ml. The child weighs 20 kg. The nurse prepares to administer one dose. How many milliliters will the enuprrsepare to a dminister one dose? Fill in the blank. Record your answer in a whole number. ANS: 6 Follow the formula for dosage calculation. Multiply 0.6 mg 20 kg to get the dose = 12 mg Desired Volume = ml per dose Available 12 mg 5 ml = 6 ml 10 mg DIF: Cognitive Level: Applying REF: MCS: 1298 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. A health care provider prescribes captopril (Capoten), 2.5 mg PO every 12 h for a child with heart failure. The medication label states: Captopril 5 mg/5 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using one decimal place. ANS: 2.5 Follow the formula for dosage calculation. Desired Volume = ml per dose Available 2.5 mg 5 ml = 2.5 ml 5 mg DIF: Cognitive Level: Applying REF: MCS: 1266 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. A health care provider prescribes acetaminophen (Tylenol) gtt, 10 mg/kg/dose PO every 4 to 6 hours as needed for fever for a child with rheumatic fever. The child weighs 8 kg. The medication label states: Acetaminophen 80 mg/0.8 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to odneceimal place. ANS: 0.8 Follow the formula for dosage calculation. Multiply 10 mg 8 kg to get the dose = 80 mg Desired Volume = ml per dose Available 80 mg 0.8 ml = 0.8 ml 80 mg Chapter 28.The Child with Hematologic or Immunologic Dysfunction MULTIPLE CHOICE 1. The regulation of red blood cell (RBC) production is thought to be controlled by which physiologic factor? a. Hemoglobin b. Tissue hypoxia c. Reticulocyte count d. Number of RBCs ANS: B Hemoglobin does not directly control RBC production. If there is insufficient hemoglobin to adequately oxygenate the tissue, then erythropoietin may be released. When tissue hypoxia occurs, the kidneys release erythropoietin into the bloodstream. This stimulates the marrow to produce new RBCs. Reticulocytes are immature RBCs. The retic count can be used to monitor hematopoiesis. The number of RBCs does not directly control production. In congenital cardiac disorders with mixed blood flow or decreased pulmonary blood flow, RBC production continues secondary to tissue hypoxia. DIF: Cognitive Level: Understanding REF: MCS: 1324 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. What physiologic defect is responsible for causing anemia? a. Increased blood viscosity b. Depressed hematopoietic system c. Presence of abnormal hemoglobin d. Decreased oxygen-carrying capacity of blood ANS: D Anemia is a condition in which the number of red blood cells or hemoglobin concentration is reduced below the normal values for age. This results in a decreased oxygen-carrying capacity of blood. Increased blood viscosity is usually a function of too many cells or of dehydration, not of anemia. A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia, but the definition depends on the decreased oxygen-carrying capacity of the blood. DIF: Cognitive Level: Understanding REF: MCS: 1328 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 3. A mother states that she brought her child to the clinic because the 3-year-old girl was not keeping up with her siblings. During physical assessment, the nurse notes that the child has pale skin and conjunctiva and has muscle weakness. The hemoglobin on admission is 6.4 g/dl. After notifying the practitioner of the results, what nursing priority intervention should occur next? a. Reduce environmental stimulation to prevent seizures. b. Have the laboratory repeat the analysis with a new specimen. c. Minimize energy expenditure to decrease cardiac workload. d. Administer intravenous fluids to correct the dehydration. ANS: C The child has a critically low hemoglobin value. The expected range is 11.5 to 15.5 g/dl. When the oxygen-carrying capacity of the blood decreases slowly, the child is able to compensate by increasing cardiac output. With the increasing workload of the heart, additional stress can lead to cardiac failure. Reduction of environmental stimulation can help minimize energy expenditure, but seizures are not a risk. A repeat hemoglobin analysis is not necessary. The child does not have evidence of dehydration. If intravenous fluids are given, they can further dilute the circulating blood volume and increase the strain on the heart. DIF: Cognitive Level: Applying REF: MCS: 1329 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. A child with severe anemia requires a unit of red blood cells (RBCs). The nurse explains to the child that the transfusion is necessary for which reason? a. Allow her parents to come visit her. b. Fight the infection that she now has. c. Increase her energy so she will not be so tired. d. Help her body stop bleeding by forming a clot (scab). ANS: C The indication for RBC transfusion is risk of cardiac decompensation. When the number of circulating RBCs is increased, tissue hypoxia decreases, cardiac function is improved, and the child will have more energy. Parental visiting is not dependent on transfusion. The decrease in tissue hypoxia will minimize the risk of infection. There is no evidence that the child is currently infected. Forming a clot is the function of platelets. DIF: Cognitive Level: Applying REF: MCS: 1329 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 5. An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of what complication? a. Air embolism b. Allergic reaction c. Hemolytic reaction d. Circulatory overload ANS: D The signs of circulatory overload include distended neck veins, hypertension, crackles, a dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema are signs and symptoms of allergic reactions.mHoelytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure. DIF: Cognitive Level: Applying REF: MCS: 1332 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. What explanation provides the rationale for why iron-deficiency anemia is common during infancy? a. Cows milk is a poor source of iron. b. Iron cannot be stored during fetal development. c. Fetal iron stores are depleted by 1 month of age. d. Dietary iron cannot be started until 12 months of age. ANS: A Children between the ages of 12 and 36 months are at risk for anemia because cows milk is a major component of their diet, and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by ages 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first 12 months of life. DIF: Cognitive Level: Analyzing REF: MCS: 1335 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. What statement best describes iron deficiency anemia in infants? a. It is caused by depression of the hematopoietic system. b. Diagnosis is easily made because of the infants emaciated appearance. c. It results from a decreased intake of milk and the premature addition of solid foods. d. Clinical manifestations are related to a reduction in the amount of oxygen available to tissues. ANS: D In iron-deficiency anemia, the childs clinical appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic system is not depressed. The bone marrow produces red blood cells that are smaller and contain less hemoglobin than normal red blood cells. Children who have iron deficiency from drinking excessive quantities of milk are usually pale and woveeigr ht. T hey are receiving sufficient ecsalbourit ar e deficient in essential rniuetnts. T he clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive intake of milk. DIF: Cognitive Level: Analyzing REF: MCS: 1335 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 8. What information should the nurse include when teaching the mother of a 9-month-old infant about administering liquid iron preparations? a. Give with meals. b. Stop immediately if nausea and vomiting occur. c. Adequate dosage will turn the stools a tarry green color. d. Allow preparation to mix with saliva and bathe the teeth before swallowing. ANS: C The nurse should prepare the mother for the anticipated change in the childs stools. If the iron dose is adequate,ethstools will b ecome a tarry ogr.eeAn lcol ack of color change may indicate insufficient iron. The iron should be given in two divided doses between meals when the presence of free hydrochloric acid is greatest. Iorrobnedisbaebs st in an acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced adnudagllry i ncreased as the child develops tolerance. Liquid preparations of iron stain the teeth; they should be administered through a straw and the mouth rinsed after administration. DIF: Cognitive Level: Applying REF: MCS: 1338 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 9. Therapeutic management of a 6-year-old child with hereditary spherocytosis (HS) should include which therapeutic intervention? a. Perform a splenectomy. b. Supplement the diet with calcium. c. Institute a maintenance transfusion program. d. Increase intake of iron-rich foods such as meat. ANS: A Splenectomy corrects the hemolysis that occurs in HS. The splenectomy is generally reserved for children older nthage 5 years with symptomatic anemia. Supplementation with calcium does not affect the HS. Additional folic acid can prevent deficiency caused by the rapid cell turnover. A maintenance transfusion program suppresses red blood cell formation. At this time, the risks of transfusion are greater than those of a splenectomy. Iron supplementation does not influence the course of HS. DIF: Cognitive Level: Understanding REF: MCS: 1339 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 10. What condition occurs when the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia ANS: B Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized ibcyiednecfi es in production of certain globulin chains. Iron-deficiency anemia affects red blood cell size and depth of color but does not involve abnormal hemoglobin. DIF: Cognitive Level: Understanding REF: MCS: 1339 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. What statement most accurately reflects inheritance of SCA? a. SCA is not inherited. b. All siblings will have SCA. c. Each sibling has a 25% chance of having SCA. d. There is a 50% chance of siblings having SCA. ANS: C SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, each child born to these parents has a 25% chance of having the disorder, a 25% chance of having neither SCA nor the trait, and a 50% chance of being heterozygous for SCA (sickle cell trait). SCA is an inherited hemoglobinopathy. DIF: Cognitive Level: Analyzing REF: MCS: 1339 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 12. The icclainl manifestations of sickle cell anemia (SCA) are primarily the urelts of which physiologic alteration? a. Decreased blood viscosity b. Deficiency in coagulation c. Increased red blood cell (RBC) destruction d. Greater affinity for oxygen ANS: C The clinical features of SCA are parilmy the result of increased RBC destruction and obstruction caused by the sickle-shaped RBCs. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. SCA does not have a coagulation deficit. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. DIF: Cognitive Level: Analyzing REF: MCS: 1340 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The childs care should include which therapeutic interventions? a. Hydration and pain management b. Oxygenation and factor VIII replacement c. Electrolyte replacement and administration of heparin d. Correction of alkalosis and reduction of energy expenditure ANS: A The management of crises includes adequate hydration, pain management, minimization of energy expenditures, electrolyte replacement, and blood component therapy if indicated. Factor VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels. Also, prolonged oxygen can reduce bone marrow activity. Heparin is not indicated in the treatment colfuvsaivseooscickle cell c risis. Electrolyte replacement shouldcaocmpany hydration. The acidosis will be corrected as the crisis is treated. Energy expenditure should be minimized to improve oxygen utilization. Acidosis, not alkalosis, results from hypoxia, which also promotes sickling. DIF: Cognitive Level: Applying REF: MCS: 1343 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 14. A child with sickle cell anemia (SCA) develops severe chest and back pain, fever, a cough, and dyspnea. What should be the first action by the nurse? a. Administer 100% oxygen to relieve hypoxia. b. Notify the practitioner because chest syndrome is suspected. c. Infuse intravenous antibiotics as soon as cultures are obtained. d. Give ordered pain medication to relieve symptoms of pain episode. ANS: B These are the symptoms of chest syndrome, which is a medical emergency. Notifying the practitioner is the priority action. Oxygen may be indicated; however, it does not reverse the sickling that has occurred. Antibiotics are not indicated initially. Pain medications may be required, but evaluation by the practitioner is the priority. DIF: Cognitive Level: Applying REF: MCS: 1348 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 15. In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling and delay the vasoocclusion and hypoxiaischemia cycle. What information should the nurse share with parents in a teaching plan? a. Encourage drinking. b. Keep accurate records of output. c. Check for moist mucous membranes. d. Monitor the concentration of the childs urine. ANS: C Children with SCA have impaired kidney function and cannot concentrate urine. Parents are taught signs of dehydration and ways to minimize loss of fluid to the environment. Encouraging drinking is not specific enough for parents. The nurse should give the parents and child a target fluid amount for each 24-hour period. Accurate monitoring of output may not reflect the childs fluid needs. Without the ability to concentrate urine, the child needs additional intake to compensate. Dilute urine and specific gravity are not valid signs of hydration status in children with SCA. DIF: Cognitive Level: Applying REF: MCS: 1347 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 16. What statement best describes -thalassemia major (Cooley anemia)? a. It is an acquired hemolytic anemia. b. Inadequate numbers of red blood cells (RBCs) are present. c. Increased incidence occurs in families of Mediterranean extraction. d. It commonly occurs in individuals from West Africa. ANS: C Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. Thalassemia is inherited as an autosomal recessive disorder. An overproduction of RBCs occurs. Although numerous, the red blood cells are relatively unstable. Sickle cell disease is common in blacks of West African descent. DIF: Cognitive Level: Understanding REF: MCS: 1349 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 17. What therapeutic intervention is most appropriate for a child with -thalassemia major? a. Oxygen therapy b. Supplemental iron c. Adequate hydration d. Frequent blood transfusions ANS: D The goal of medical management is to maintain sufficient hemoglobin (>9.5 g/dl) to prevent bone marrow expansion. This is achieved through a long-term transfusion program. Oxygen therapy and adequate hydration are not beneficial in the overall management of thalassemia. The child does not require supplemental iron. Iron overload is a problem because of frequent blood transfusions, decreased production of hemoglobin, and increased absorption from the gastrointestinal tract. DIF: Cognitive Level: Applying REF: MCS: 1349 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. Iron overload is a side effect of chronic transfusion therapy. What treatment assists in minimizing this cpolimcation? a. Magnetic therapy b. Infusion of deferoxamine c. Hemoglobin electrophoresis d. Washing red blood cells (RBCs) to reduce iron ANS: B Deferoxamine infusions in combination with vitamin C allow the iron to remain in a more chelatable form. The iron can then be excreted more easily. Use of magnets does not remove additional iron from the body. Hemoglobin electrophoresis is used to confirm the diagnosis of hemoglobinopathies; it does not affect iron overload. Washed RBCs remove white blood cells and other proteins from the unit of blood; they do not affect the iron concentration. DIF: Cognitive Level: Applying REF: MCS: 1353 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 19. In which condition are all the formed elements of the blood simultaneously depressed? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia ANS: A Aplastic anemia refers to a bone marrow failure condition in which the formed elements of the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by abnormal sickled hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin chains. Iron-deficiency anemia results in a decreased amount of circulating red cells. DIF: Cognitive Level: Understanding REF: MCS: 1354 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 20. For children who do not have a matched sibling bone marrow donor, the therapeutic management of aplastic anemia includes what intervention? a. Antibiotics b. Antiretroviral drugs c. Iron supplementation d. Immunosuppressive therapy ANS: D It is thought that aplastic anemia may be an autoimmune disease. Immunosuppressive therapy, including antilymphocyte globulin, antithymocyte globulin, cyclosporine, granulocyte colony- stimulating factor, and methylprednisone, has greatly improved the prognosis for patients with aplastic anemia.bAionttiics are not i ndicated as the management. They may be indicated for infections. Antiretroviral drugs and iron supplementation are not part of the therapy. DIF: Cognitive Level: Applying REF: MCS: 1355 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 21. What statement siscrdieptive of most cases of hemophilia? a. X-linked recessive deficiency of platelets causing prolonged bleeding b. X-linked recessive inherited disorder in which a blood clotting factor is deficient c. Autosomal dominant deficiency of a factor involved in the blood-clotting reaction d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped ANS: B The inheritance pattern in 80% of all the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease). The disorder involves coagulation factors, not platelets. The disorder does not involve red blood cells or the Y chromosome. DIF: Cognitive Level: Understanding REF: MCS: 1357 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 22. The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about home care. What should the nurse tell the family to do to minimize joint injury? a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs). b. Administer DDAVP (synthetic vasopressin). c. Provide intravenous (IV) infusion of factor VIII concentrates. d. Encourage elevation and application of ice to the involved joint. ANS: C Parents are taught home infusion of factor VIII concentrate. For moderate and severe hemophilia, prompt IV administration is essential to vperent joint injury. NSAIDs are effective for pain relief. They must be given with caution because they inhibit platelet aggregation. A factor VIII level of 30% is necessary to stop bleeding. DDAVP can raise the factor IVIIl evel fourfold. Moderate hemophilia is defined by a factor VIII activity of 4.9. A fourfold increase would not meet the 30% level. Ice and elevation are important adjunctive therapy, but factor VIII is necessary. DIF: Cognitive Level: Applying REF: MCS: 1359 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 23. What condition is an acquired hemorrhagic disorder that is characterized by excessive destruction of platelets? a. Aplastic anemia b. Thalassemia major c. Idiopathic thrombocytopenic purpura d. Disseminated intravascular coagulation ANS: C Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and normal bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major ois a gr up of blood disorders characterized by deficiency in the production rate of specific hemoglobin chains. Disseminated ianvtarscular co agulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma. DIF: Cognitive Level: Understanding REF: MCS: 1362 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 24. Care for the child with acute idiopathic thrombocytopenic purpura (ITP) includes which therearpveeuntitcioinn?t a. Splenectomy b. Intravenous administration of anti-D antibody c. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) d. Helping child participate in sports ANS: B Anti-D antibody causes an increase in platelet count iampparteolxy 48 hours after administration. Splenectomy is reserved for chronic severe ITP not responsive to pharmacologic management. NSAIDs are not used in ITP. Both NSAIDs and aspirin interfere with platelet aggregation. The nurse works with the child and parents to choose quiet activities while the platelet count is below 100,000/mm3. DIF: Cognitive Level: Analyzing REF: MCS: 1362 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 25. A toddler is diagnosed with chronic benign neutropenia. The parents are being taught about caring for their child. What information is important to include? a. Avoid large indoor crowds and people who are ill. b. Parenteral antibiotics are necessary to control disease. c. Frequent rest periods are needed during the daytime. d. List the side effects of corticosteroids used to decrease inflammation. ANS: A The parents are taught to minimize risk of infection by avoiding crowded areas and individuals who are ill. Parents are also cautioned about when to notify their practitioner and administration of granulocyte colony-stimulating factor, if indicated. Antibiotics are not needed unless the child has an infection. The toddler does not need any additional rest as a result of the neutropenia. Corticosteroids are not indicated. DIF: Cognitive Level: Applying REF: MCS: 1365 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 26. The majority of children in the United States with human immunodeficiency virus (HIV) infection acquired the disease by whichsm? ean a. Through sexual contact b. From a blood transfusion c. By using intravenous (IV) drugs d. Perinatally from their mothers ANS: D More than 90% of the children with HIV under 13 years who were reported to the Centers for Disease Control and Prevention acquired the infection during the perinatal period. With intervention, the number of children infected can be decreased. Sexual contact and IV drug use are the leading causes of infection in the 14- to 19-year age group. This number is less than the number of cases in the under 13-year age group. Transfusion has accounted for 3% to 6% of all pediatric acquired immunodeficiency syndrome cases to date. Before 1985 and routine screening of donated blood products, children with hemophilia were at great risk from pooled plasma products. DIF: Cognitive Level: Understanding REF: MCS: 1369 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral drugs. What is the purpose of these drugs? a. Cure the disease. b. Delay disease progression. c. Prevent spread of infection. d. Treat Pneumocystis carinii pneumonia. ANS: B Although not a cure, these antiretroviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. At this time, cure is not possible. Antiretroviral drugs do not prevent the spread of the disease. MCS: carinii prophylaxis is accomplished with antibiotics. DIF: Cognitive Level: Understanding REF: MCS: 1370 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 28. The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. What is the priority nursing goal? a. Prevent infection. b. Prevent secondary cancers. c. Identify source of infection. d. Restore immunologic defenses. ANS: A As a result of the immunocompromise that is associated with human immunodeficiency virus (HIV) infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the childs normal developmental needs. Preventing secondary cancers is not currently possible. Case finding is not a priority nursing goal in planning care for an individual. Current drug therapy is affecting the disease progression; although not easceudreru, gths can sup press viral replication, preventing further deterioration but not actually restoring immunologic defenses. DIF: Cognitive Level: Applying REF: MCS: 1370 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 29. The school nurse is informed that a child with human immunodeficiency virus (HIV) infection will be attending school soon. What is an important nursing intervention to include in the plan of care? a. Carefully follow universal precautions. b. Inform the parents of the other children. c. Determine how the child became infected. d. Reassure other children that they will not become infected. ANS: A Universal precautions are necessary to prevent rfuther transmission of the disease. Informing the parents of the other children would vatieolthe iclhds right to cpyri.va It is not within the role of the school nurse to determine how the child became infected. Reassuring other children that they will not become infected violates the childs privacy. General health classes can discuss prevention of HIV transmission. DIF: Cognitive Level: Applying REF: MCS: 1371 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 30. What condition is an inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated immunity? a. Fanconi syndrome b. Wiskott-Aldrich syndrome c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency syndrome (SCIDS) ANS: D SCIDS is a genetic disorder that friecsiutsltsofin de both humoral and cellular immunity. Fanconi syndrome is a hereditary disorder of red blood cell production. Wiskott-Aldrich syndrome is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes. AIDS is not inherited. DIF: Cognitive Level: Understanding REF: MCS: 1373 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 31. The nurse is preparing a community outreach program about the prevention of iron- deficiency anemia in infants. What statement should the nurse include in the program? a. Whole milk can be introduced into the infants diet in small amounts at 6 months. b. Iron supplements cannot be given until the infant is older than 1 year of age. c. Iron-fortified cereal should be introduced to the infant at 2 months of age. d. Breast milk or iron-fortified formula should be used for the first 12 months. ANS: D Prevention, the primary goal in iron-deficiency anemia, is achieved through optimal nutrition and appropriate iron supplements. The American Academy of Pediatrics recommends feeding an infant only breast milk or iron-fortified formula for the first 12 months of life. Whole cows milk should not be introduced until after 12 months, iron supplements can be given during the first year of life, and iron-fortified cereals should not be introduced until the infant is 4 to 6 months old. DIF: Cognitive Level: Applying REF: MCS: 1336 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 32. A 5-year-old child is admitted to the hospital inkalesicc ell crisis. The lcdhiha s bneae lert and oriented but in severe pain. The nurse notes that the child is complaining of a headache and is having unilateral hemiplegia. What action should the nurse implement? a. Notify the health care provider. b. Place the child on bed rest. c. Administer a dose of hydrocodone (Vicodin). d. Start O2 per the hospitals protocol. ANS: A Any number of neurologic symptoms can indicate a minor cerebral insult, such as headache, aphasia, weakness, convulsions, visual disturbances, or unilateral hemiplegia. Loss of vision is usually the sreult of progressive retinopathy and retinal detachment. The nurse should notify the health care provider. DIF: Cognitive Level: Applying REF: MCS: 1343 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 33. What pain medication is contraindicated in children with sickle cell disease (SCD)? a. Meperidine (Demerol) b. Hydrocodone (Vicodin) c. Morphine sulfate d. Ketorolac (Toradol) ANS: A Meperidine (pethidine [Demerol]) is not recommended. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Patients with SCD are particularly at risk for normeperidine-induced seizures. DIF: Cognitive Level: Analyzing REF: MCS: 1347 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 34. In anticipation of the admission of a child with hereditary spherocytosis (HS) who is experiencing an aplastic crisis, what action should the nurse plan? a. Secure an isolation room. b. Prepare for a transfusion of packed red blood cells. c. Anticipate preoperative preparation for a splenectomy. d. Gather equipment and medication for treatment of shock. ANS: B In hereditary spherocytosis, aplastic crisis results in a sudden cessation Cof RB production by the bone marrow. Hemoglobin and hematocrit values drop rapidly, which results in severe anemia. Transfusion support may be needed, and close monitoring of the childs cardiovascular status is necessary. The nurse should prepare for a transfusion of packed red blood cells initially. An isolation room is not needed, splenectomy would not be done at this time, and the child will not be in shock. DIF: Cognitive Level: Applying REF: MCS: 1338 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 35. A child with hemophilia A will have which abnormal laboratory result? a. PT (ProTime) b. Platelet count c. Fibrinogen level d. PTT (partial thromboplastin time) ANS: D The basic defect ophielmia A i s a deficiency of factor VIII. The ipaart l thromboplastin time measures abnormalities in the sinictrpina thway (mabanloitries in f actors I, II, V, VIII, IX, X, XII, HMK, and KAL). The prothrombin time measures abnormalities of the extrinsic pathway (abnormalities in factors I, II, V, VII, and X). Fibrinogen level is not dependent on the intrinsic pathway. Platelets are not affected with hemophilia A. DIF: Cognitive Level: Analyzing REF: MCS: 1356 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 36. A child with hemophilia A is scheduled for surgery. What precautions should the nurse institute with this child? a. Handle the child gently when transferring to a cart. b. Caution the child not to brush his teeth before surgery. c. Use tape sparingly on postoperative dressings. d. Do not administer analgesics before surgery. ANS: A The goal of prevention of bleeding episodes is directed toward decreasing the risk of injury. The child should be handled carefully when transferring to a cart. Brushing teeth, use of tape, and giving analgesics will not risk a bleeding episode. DIF: Cognitive Level: Applying REF: MCS: 1359 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 37. Nursing strategies to improve the growth and development of the child with human immunodeficiency virus (HIV) infection should include what? a. Provide only those foods that the child feels like eating. b. Fortify foods with nutritional supplements to maximize quality of intake. c. Weigh the child and measure height and muscle mass on a daily basis. d. Provide high-fat and high-calorie meals and snacks to meet body requirements for growth. ANS: B HIV icntifoen of ten leads torma ked failure to thrive and multiple nutritional deficiencies. Nutritional management may be difficult because of recurrent illness, diarrhea, and other physical problems. The nurse should implement intensive nutritional interventions if the childs growth begins to slow or weight begins to decrease. Fortifying foods with nutritional supplements will maximize quality of intake. The child does not need to be weighed daily, and high-fat meals and snacks should not be encouraged. DIF: Cognitive Level: Applying REF: MCS: 1371 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 38. What medication is classified as an antiretroviral? a. Dapsone (Aczone) b. Pentamidine (Pentam) c. Didanosine (Videx) d. Trimethoprimsulfamethoxazole (Bactrim) ANS: C Classes of antiretroviral agents include nucleoside reverse transcriptase inhibitors (e.g., zidovudine, didanosine, stavudine, lamivudine, abacavir), nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine, delavirdine, efavirenz), and protease inhibitors (e.g., indinavir, saquinavir, ritonavir, nelfinavir, amprenavir, lopinavir, ritonavir). Dapsone, pentamidine, and Bactrim are anti-infectives. DIF: Cognitive Level: Analyzing REF: MCS: 1370 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 39. The nurse is caring for a child with hemophilia A. The childs activity is as tolerated. What activity is contraindicated for this child? a. Ambulating to the cafeteria b. Active range of motion c. Ambulating to the playroom d. Passive range of motion exercises ANS: D Passive range of motion ceixseers should ne r bve rteopfa an exercise regimen after an acute episode because the joint capsule could easily be stretched and bleeding could recur. Active range of motion exercises are best so that the patient can gauge his or her own pain tolerance. The child can ambulate to the playroom or the cafeteria. DIF: Cognitive Level: Applying REF: MCS: 1348 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 40. What condition precipitates polycythemia? a. Dehydration b. Severe infections c. Immunosuppression d. Prolonged tissue hypoxia ANS: D Oxygen transport depends on both the number of circulating RBCs and the amount of normal hemoglobin in the cell. This explains why polycythemia (increase in the number of erythrocytes) occurs in conditions characterized by prolonged tissue hypoxia, such as cyanotic heart defects. Dehydration, severe infections, or immunosuppression will not precipitate polycythemia. DIF: Cognitive Level: Understanding REF: MCS: 1324 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 41. The clinic nurse is evaluating lab results for a child. What recorded hemoglobin (Hgb) result is considered within the normal range? a. 9 g/dl b. 10 g/dl c. 11 g/dl d. 12 g/dl ANS: D Normal hemoglobin (Hgb) determination is 11.5 to 15.5 g/dl. DIF: Cognitive Level: Understanding REF: MCS: 1326 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 42. The icclinur se is ealvuating lab results for a child. What recorded hematocrit (Hct) result is considered within the mnoarl range? a. 30% b. 40% c. 50% d. 60% ANS: B Normal hematocrit (Hct) is 35% to 45%. DIF: Cognitive Level: Understanding REF: MCS: 1326 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 43. The nurse is caring for a school-age child with severe anemia and activity intolerance. What diversional uacldtivthitey sho enuprls n a for this child? a. Playing a musical instrument b. Playing board or card games c. Participating in a game of table tennis d. Participating in decorating the hospital room ANS: B Plan diversional activities that promote rest but prevent boredom and withdrawal. Because short attention span, irritability, and restlessness are common inia aenmd increase stress demands on the body, plan appropriate activities such as playing board or cardegsa. mP laying a musical instrument, participating in a game of table tennis, or decorating the hospital room would cause undue exertion. DIF: Cognitive Level: Applying REF: MCS: 1331 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 44. The nurse is preparing to administer a unit of packed red blood cells to a hospitalized child. What is an appropriate action that applies to administering blood? a. Take the vital signs every 15 minutes while blood is infusing. b. Use blood within 1 hour of its arrival from the blood bank. c. Administer the blood with 5% glucose in a piggyback setup. d. Administer the first 50 ml of blood slowly and stay with the child. ANS: D The nurse should administer the first 50 ml of blood or initial 20% of volume (whichever is smaller) slowly and stay with the iclhd. Vitals signs should be ntake 15 minutes after initiation and then every hour, not every 15 minutes. Blood should be used within 30 minutes, not 1 hour. Normal saline, not 5% glucose, should be the IV solution. DIF: Cognitive Level: Applying REF: MCS: 1334 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 45. What rationale explains why prolonged use of oxygen should be discouraged in a child with anemia? a. Prolonged use of oxygen can decrease erythropoiesis. b. Prolonged use of oxygen can interfere with iron production. c. Prolonged use of oxygen interferes with a childs appetite. d. Prolonged use of oxygen can affect the synthesis of hemoglobin. ANS: A Oxygen administration is of limited value, because each gram of hemoglobin is able to carry a limited amount of the gas. In addition, prolonged use of supplemental oxygen can decrease erythropoiesis. Prolonged use of oxygen does not interfere with iron production, a childs appetite, or affect the synthesis of hemoglobin. DIF: Cognitive Level: Analyzing REF: MCS: 1348 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 46. The nurse is teaching a parent of an infant to limit the amount of formula to encourage the intake of iron-rich food. What amount should the nurse teach to the parent? a. 500 ml b. 750 ml c. 1000 ml d. 1250 ml ANS: C The nurse should teach the parent to limit the amount of formula to no more than 1 1/day to encourage intake of iron-rich solid foods. DIF: Cognitive Level: Applying REF: MCS: 1336 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 47. A cldhiwith s ickle cell disease is in a vasoocclusive crisis. What nonpharmacologic pain intervention should the nurse plan? a. Exercise as a distraction b. Heat to the affected area c. Elevation of the extremity d. Cold compresses to the affected area ANS: B Frequently, heat to the affected area is soothing. Cold compresses are not applied to the area because doing so enhances vasoconstriction and occlusion. Bed rest is usually well tolerated during a crisis, although the actual rest obtained depends a great deal on pain alleviation and the use of organized schedules of nursing care. Although the objective of bed rest is to minimize oxygen consumption, some activity, particularly passive range of motion exercises, is beneficial to promote circulation. Usually the best course is to let children determine rthaecitivity tolerance. Elevating the extremity will not help in sickle cell disease. DIF: Cognitive Level: Applying REF: MCS: 1348 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 48. What immunoglobulin pattern does the nurse expect in a child recently diagnosed with Wiskott-Aldrich syndrome? a. Diminished levels of IgG b. Diminished levels of IgA c. Diminished levels of IgM d. Diminished levels of IgE ANS: C The level of IgM is diminished rea ly in the course of the disease, but levels of IgG, IgA, and IgE may be elevated initially. DIF: Cognitive Level: Analyzing REF: MCS: 1367 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a 14-year-old child with disseminated intravascular coagulation (DIC). What clinical manifestations should the nurse expect tovoeb?se(Srelect all that apply.) a. Petechiae b. Chronic diarrhea c. Hepatosplenomegaly d. Bleeding from openings in the skin e. Hypotension f. Purpura ANS: A, D, E, F Some clinical manifestations of DIC are petechiae, bleeding from openings in the skin, hypotension, and purpura. Hepatosplenomegaly and chronic diarrhea are clinical manifestations of human immunodeficiency virus (HIV) infection in children. DIF: Cognitive Level: Analyzing REF: MCS: 1364 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. What activity should the school nurse recommend for a child with hemophilia A? (Select all that apply.) a. Golf b. Soccer c. Rugby d. Jogging e. Swimming ANS: A, D, E Children and adolescents with severe hemophilia can participate in noncontact sports such as swimming, golf, walking, jogging, fishing, and bowling. Contact sports such as football, boxing, hockey, soccer, and rugby are strongly discouraged because the risk of injury outweighs the physical and psychosocial benefits of participating in these sports. DIF: Cognitive Level: Applying REF: MCS: 1360 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. What are signs and symptoms of anemia? (Select all that apply.) a. Pallor b. Fatigue c. Dilute urine d. Bradycardia e. Muscle weakness ANS: A, B, E Signs and symptoms of anemia include, pallor, fatigue, and muscle weakness. Tachycardia, not bradycardia, and dark urine, not dilute, are signs and symptoms of anemia. DIF: Cognitive Level: Analyzing REF: MCS: 1329 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. The nurse is administering a unit of blood to a child. What are signs and symptoms of a transfusion reaction? (Select all that apply.) a. Chills b. Shaking c. Flank pain d. Hypothermia e. Sudden severe headache ANS: A, B, C, E Signs and symptoms of a transfusion reaction include chills, shaking, flank pain, and sudden severe headache. Hyperthermia, not hypothermia, occurs. DIF: Cognitive Level: Applying REF: MCS: 1332 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 5. The nurse is teaching parents of a child being discharged from the hospital after a splenectomy about the risk of infection. What should the nurse include in the teaching session? (Select all that apply.) a. Avoid obtaining the pneumococcal vaccination for the child. b. Avoid obtaining the meningococcal vaccination for the child. c. The child should receive prophylactic penicillin for certain procedures. d. Have the child immunized with the Haemophilus influenzae type b vaccination. e. Notify the health care provider if your child develops a fever of 38.5 C (101.3 F). ANS: C, D, E Because of the risk of life-threatening bacterial infection after splenectomy, these children are immunized with the pneumococcal, meningococcal, and H. influenzae type b vaccines before surgery and receive prophylactic penicillinrfos everal years after splenectomy. The parents should be tirnuscted in thetanciemopfor seeking iemdimate medical attention if their child develops a fever of 38.5 C (101.3 F) or higher as a common sign of infection or postsplenectomy sepsis. DIF: Cognitive Level: Applying REF: MCS: 1339 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. The clinic nurse is evaluating causes for iron deficiency caused by inadequate supply of iron. What should the nurse recognize as causes for iron deficiency caused by an inadequate iron supply? (Select all that apply.) a. Prematurity b. Slow growth rate c. Excessive milk intake d. Severe iron deficiency in the mother e. Exclusive breastfeeding of infant from birth to 3 months ANS: A, C, D Causes for iron deficiency caused by an inadequate supply of iron include prematurity, excessive milk intake, and severe iron deficiency in the mother. Rapid growth rate, not slow, and exclusive breastfeeding of infant after 6 months, not from birth to 3 months, can be causes of inadequate supply of iron. DIF: Cognitive Level: Analyzing REF: MCS: 1335 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. The clinic nurse is evaluating causes for iron deficiency due to impaired iron absorption. What should the nurse recognize as causes for iron deficiency due to impaired iron absorption? (Select all that apply.) a. Gastric acidity b. Chronic diarrhea c. Lactose intolerance d. Absence of phosphates e. Inflammatory bowel disease ANS: B, C, E Causes for iron deficiency due to impaired iron absorption include chronic diarrhea, lactose intolerance, and inflammatory bowel disease. Gastric alkalinity, not acidity, and the presence, not absence, of phosphates can be causes of impaired iron absorption. DIF: Cognitive Level: Analyzing REF: MCS: 1335 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. The nurse is preparing to admit a 1-month-old infant with severe congenital neutropenia (Kostmann disease). What clinical features of severe congenital neutropenia should the nurse recognize? (Select all that apply.) a. Anemia is present. b. Neutropenia is present. c. The illness is severe. d. It has a dominant inheritance pattern. e. There are decreased eosinophils in the bone marrow. ANS: B, C The clinical features of severe congenital neutropenia include anemia and neutropenia, and the illness is severe. It has an autosomal recessive inheritance pattern, and there are increased, not decreased, eosinophils in the bone marrow. DIF: Cognitive Level: Analyzing REF: MCS: 1365 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. The nurse is preparing to admit a 4-year-old child with chronic benign neutropenia. What clinical features of chronic benign neutropenia should the nurse recognize? (Select all that apply.) a. Gingivitis is present. b. Anemia is not present. c. Monocytosis is present. d. It has an autosomal recessive pattern. e. Treatment is by bone marrow transplantation. ANS: A, B, C The clinical features of chronic benign neutropenia include gingivitis, no anemia, and monocytosis. It is not inherited, and because it is benign, it does not require treatment except antibiotics as indicated. DIF: Cognitive Level: Analyzing REF: MCS: 1365 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 10. The nurse is caring for a 12-year-old child with -thalassemia. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Anorexia b. Unexplained fever c. Enlarged spleen or liver d. Bronzed, freckled complexion e. Precocious sexual development ANS: A, B, C, D The clinical manifestations of -thalassemia include anorexia; unexplained fever; an enlarged spleen or liver; and a bronzed, freckled complexion. There is delayed sexual maturation, not precocious. DIF: Cognitive Level: Analyzing REF: MCS: 1352 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity COMPLETION 1. A health care provider prescribes morphine sulfate, 0.2 mg/kg IV every 2 to 4 hours as needed for pain for a child with sickle cell disease. The child weighs 20 kg. The medication label states: Morphine sulfate 5 mg/ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using one decimal place. ANS: 0.8 Follow the formula for dosage calculation. Multiply 0.2 mg 20 kg to get the dose = 4 mg Desired Volume = ml per dose Available 4 mg 1 ml = 0.8 ml 10 mg DIF: Cognitive Level: Applying REF: MCS: 1347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The health care provider has prescribed a unit of packed red blood cells to be administered over 3 hours to a child with sickle cell disease. The unit from the blood bank totals 240 ml. What milliliters per hour should the nurse set the infusion pump to deliver the packed red blood cells? Fill in the blank and record your answer in a whole number. ANS: 80 Perform the calculation. 240 ml/3 hours = 80 ml/hr DIF: Cognitive Level: Applying REF: MCS: 1334 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. A health care provider prescribes iron (Niferex) elixir, 2 mg/kg orally daily faorp reterm infant. The infant weighs 4 kg. The medication label states: Niferex 100 mg/5 ml. The nurse prepares to administer one dose. How many milliliters will the enuprrs dose? Fill in the blank. Record your answer using one decimal place. epare to administer one ANS: 0.4 Follow the formula for dosage calculation. Multiply 2 mg 4 kg to get the dose = 8 mg Desired Volume = ml per dose Available 8 mg 5 ml = 0.4 ml 100 mg DIF: Cognitive Level: Applying REF: MCS: 1336 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. The child with lseicckell d isease requires 150% of the 24-hour fluid maintenance. Calculate the 24-hour maintenance fluid requirement (ml/day) for a child with sickle cell disease weighing 12 kg. Fill in the blank. Record your answer in a whole number. ANS: 1650 Follow the mfour la f or daily dflurei quirements f or children. First 10 kg: 100 ml/kg/day 10 kg = 1000 ml/day Second 10 kg: 50 ml/kg/day 2 kg = 100 ml/day = 1100 ml Divide 1100/2 to get the additional fluids needed for 150% maintenance requirement. = 550 Add 1100 + 550 = 1650 ml DIF: Cognitive Level: Applying REF: MCS: 1339 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. A health care provider prescribes ibuprofen (Motrin), 5 mg/kg PO every 6 to 8 hours as needed for pain for a child with sickle cell disease. The child weighs 16 kg. The medication label states: Ibuprofen 100 mg/5 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number. ANS: 4 Follow the formula for dosage calculation. Multiply 5 mg 16 kg to get the dose = 80 mg Desired Volume = ml per dose Available 80 mg 5 ml = 4 ml 100 mg DIF: Cognitive Level: Applying REF: MCS: 1347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. A health care provider prescribes OxyContin (Oxycodone), 7.5 mg PO every 4 to 6 hours as needed for pain for tahcshiild wi ckle cell disease. The medication label states: OxyContin 5 mg/1 ml. The nurse pareres to administer one dose.wHomantyerms w illili ill the sneurpr paere to administer one dose? Fill in the blank. Record your answer using one decimal place. ANS: 1.5 Follow the formula for dosage calculation. Desired Volume = ml per dose Available 5 mg 1 ml = 1.5 ml 5 mg DIF: Cognitive Level: Applying REF: MCS: 1347 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. A health care provider prescribes Kytril (granisetron), 10 mcg/kg IV every 4 to 6 hours as needed for nausea for a child who had a reaction to a blood transfusion. The medication label states: Kytril 100 mcg/1 ml. The child weighs 20 kg. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number. ANS: 2 Follow the formula for dosage calculation. Multiply 10 mcg 20 kg to get the dose = 200 mcg Desired Volume = ml per dose Available 200 mcg 1 ml = 2 ml 100 mcg Chapter 29.The Child with Cancer MULTIPLE CHOICE 1. What childhood cancer may demonstrate patterns of inheritance that suggest a familial basis? a. Leukemia b. Retinoblastoma c. Rhabdomyosarcoma d. Osteogenic sarcoma ANS: B Retinoblastoma is an example of a pediatric cancer that demonstrates inheritance. The absence of the retinoblastoma gene allows for abnormal cell growth and the development of retinoblastoma. Chromosome abnormalities are present in many malignancies. They do not indicate a familial pattern of inheritance. The Philadelphia chromosome is observed in almost all individuals with chronic myelogenous leukemia. There is no evidence of a familial pattern of inheritance for rhabdomyosarcoma or osteogenic sarcoma cancers. DIF: Cognitive Level: Understanding REF: MCS: 1379 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. As part of the diagnostic evaluation of a child with cancer, biopsies are important for staging. What statement nexsplai what staging means? a. Extent of the disease at the time of diagnosis b. Rate normal cells are being replaced by cancer cells c. Biologic characteristics of the tumor or lymph nodes d. Abnormal, unrestricted growth of cancer cells producing organ damage ANS: A Staging is a description of the extent of the disease at the time of diagnosis. Staging criteria exist for most tumors. The stage usually raetel s directly to tphreognosis; the higher t he stage, the poorer the prognosis. The rate that normal cells are being replaced by cancer cells is not a definition of staging. Classification of the oturmrefers to th e biologic characteristics of the tumor or lymph nodes. Abnormal, unrestricted growth of cancer cells producing organ damage describes how cancer cells grow and can cause damage to an organ. DIF: Cognitive Level: Understanding REF: MCS: 1400 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 3. What statement aretel d to cl inical trials developed for ipaetdric cancers is most accurate? a. Are accessible only in major pediatric centers b. Do not require consent for standard therapy c. Provide the best available therapy compared with an expected improvement d. Are standardized to provide the same treatment to all children with the disease ANS: C Most clinical trials have a control group in which the patients receive the best available therapy currently known. The experimental group(s) receives treatment that is thought to be even better. The protocol outlines the therapy plan. Protocols are developed for many pediatric cancers. They can be accessed by pediatric oncologists throughout the United States. Consent is always required in treatment of children, especially for research protocols. The protocol is designed to optimize therapy for children based on disease type and stage. DIF: Cognitive Level: Understanding REF: MCS: 1382 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 4. Chemotherapeutic agents are classified according totwf ha eature? a. Side effects b. Effectiveness c. Mechanism of action d. Route of administration ANS: C Chemotherapeutic agents are classified according to mechanism of action. For example, antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further deoxyribonucleic acid (DNA) synthesis. Although the side effect profiles may be similar for drugs within a classification, they are not the basis for classification. Most chemotherapeutic regimens contain combinations of drugs. The effectiveness of any one drug is relative to the cancer type, combination therapy, and protocol for administration. The route of administration is determined by the pharmacodynamics and pharmacokinetics of each drug. DIF: Cognitive Level: Understanding REF: MCS: 1383 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. What type of chemotherapeutic agent earlts the function of cells by replacing a hydrogen atom of a molecule? a. Plant alkaloids b. Antimetabolites c. Alkylating agents d. Antitumor antibiotics ANS: C Alkylating agents replace a hydrogen atom with an alkyl group. The irreversible combination of alkyl groups with nucleotide chains, particularly deoxyribonucleic acid (DNA), causes unbalanced growth of unaffected cell constituents so that the cell eventually dies. Plant alkaloids arrest the cell in metaphase by binding to proteins needed for spindle formation. Antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further DNA synthesis. Antitumor antibiotics are anlatsuurbstances tha t interfhecre wit lle division by reacting with DNA in such a way as to prevent further replication of DNA and transcription of ribonucleic acid (RNA). DIF: Cognitive Level: Understanding REF: MCS: 1383 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 6. What side effect commonly occurs with corticosteroid (prednisone) therapy? a. Alopecia b. Anorexia c. Nausea and vomiting d. Susceptibility to infection ANS: D Corticosteroids have immunosuppressive effects. Children who are taking prednisone are susceptible to eincftions. H air loss is not faescitde ef of corticosteroid therapy. Children taking corticosteroids have increased appetites. Gastric irritation, not nausea and vomiting, is a potential side effect. The medicine should be given with food. DIF: Cognitive Level: Understanding REF: MCS: 1404 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. What chemotherapeutic agent is classified as an antitumor antibiotic? a. Cisplatin (Platinol AQ) b. Vincristine (Oncovin) c. Methotrexate (Texall) d. Daunorubicin (Cerubidine) ANS: D Daunorubicin is an antitumor antibiotic. Cisplatin is classified as an alkylating agent. Vincristine is a plant alkaloid. Methotrexate is an antimetabolite. DIF: Cognitive Level: Understanding REF: MCS: 1383 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate? a. Recheck the rate of drug infusion. b. Stop the drug infusion immediately. c. Observe the child closely for next 10 minutes. d. Explain to the child that this is an expected side effect. ANS: B When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate can be confirmed at amlea.teOr ti bservation of the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an allergic reaction, not an expected response. DIF: Cognitive Level: Applying REF: MCS: 1384 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 9. Total-body irradiation is indicated for what reason? a. Palliative care b. Lymphoma therapy c. Definitive therapy for leukemia d. Preparation for bone marrow transplant ANS: D Total-body irradiation is used as part of the destruction of the childs immune system necessary for a bone marrow atrnsplant. T he child is at great risk for complications because there is no supportive therapy until engraftment of the donor marrow takes place. Irradiation for palliative care is done selectively. The area that is causing pain or potential obstruction is irradiated. Lymphoma and leukemia are treated through a combination of modalities. Total-body irradiation is not indicated. DIF: Cognitive Level: Understanding REF: MCS: 1384 TOP: Nursing oPcress: Assessment MSC: iCelnt Needs: Physiological Integrity 10. The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary. What information should the nurse recognize as important when discussing this wthi the family? a. BMT should be done at the time of diagnosis. b. Parents and siblings of the child have a 25% chance of being a suitable donor. c. If BMT fails, chemotherapy or radiotherapy will need to be continued. d. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system. ANS: D The most successful TBsMcom e from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy or radiotherapy. Usually, parents only ashre a pproximately 50% of the genetic material withitrhe children. A one in four chance exists that two siblings will have two identical haplotypes and will be identically matchedeatHth LA loci. The decision to continue chemotherapy or radiotherapy if BMT fails is not appropriate to discuss with the parents when planning the BMT. That decision will be made later. DIF: Cognitive Level: Applying REF: MCS: 1385 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 11. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which method? a. Bone grafting b. Intravenous infusion c. Bone marrow injection d. Intraabdominal infusion ANS: B Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the recipients marrow and repopulate it. DIF: Cognitive Level: Applying REF: MCS: 1386 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 12. After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis syndrome includes which therapeutic intervention? a. Hydration b. Oxygenation c. Corticosteroids d. Pain management ANS: A Acute tumor lysis syndroumltsefres rom the release of intracellular metabolites during the ainliti treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis syndrome. DIF: Cognitive Level: Analyzing REF: MCS: 1387 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 13. Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which therapeutic intervention? a. Restrict oral fluids. b. Institute strict isolation. c. Use good hand-washing technique. d. Give immunizations appropriate for age. ANS: C Good hand washing minimizes the exposure to infectious organisms and decreases the chance of infection spread. Oral fluids are encouraged if the child is able to drink. If possible, the intravenous route is not used because of the increased risk of infection from parenteral fluid administration. Strict isolation is not indicated. When the child is immunocompromised, the vaccines are not effective. If necessary, the appropriate immunoglobulin is administered. DIF: Cognitive Level: Applying REF: MCS: 1393 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 14. In teaching parents how to minimize or prevent bleeding episodes when the child is myelosuppressed, the nurse includes what information? a. Meticulous mouth care is essential to avoid mucositis. b. Rectal temperatures are necessary to monitor for infection. c. Intramuscular injections are preferred to intravenous ones. d. Platelet transfusions are given to maintain a count greater than 50,000/mm3. ANS: A The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family are taught how to perform good oral hygiene to minimize gingival bleeding and mucositis. Rectal temperatures are avoided tonmimi ize the risk of ulceration. Hygiene is also emphasized. Intramuscular injections are avoided because of the risk of bleeding into the muscle and of infection. Platelet transfusions are usually not given unless there is active bleeding or the platelet count is less than 10,000/mm3. Tushe e of platelets when not necessary can contribute to antibody formation and increased destruction of platelets when transfused. DIF: Cognitive Level: Applying REF: MCS: 1392 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 15. A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. What is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments? a. Administer the chemotherapy between meals. b. Give an antiemetic before chemotherapy begins. c. Have the child bring favorite foods for snacks. d. Keep the child NPO (nothing by mouth) until nausea and vomiting subside. ANS: B The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer a 5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the chemotherapy is begun. Ttohpergeovaenl tisanticipatory signs and symptoms. The child will experience nausea with chemotherapy whether or not food is present in the stomach. Because some children develop aversions to foods eaten during chemotherapy, refraining from offering favorite foods is advised. Keeping the child NPO until nausea and vomiting subside will help with this episode, but the child will have discomfort and be at risk for dehydration. DIF: Cognitive Level: Applying REF: MCS: 1393 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16. A young child with leukemia has anorexia and severe stomatitis. What approach should the nurse suggest that the parents try? a. Relax any eating pressures. b. Firmly insist that the child eat normally. c. Serve foods that are either hot or cold. d. Provide only liquids because chewing is painful. ANS: A A multifaceted approach is necessary for lcdhrien with severe stomatitis and anorexia. F irst, the parents should relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. Insisting that the child eat normally is not suggested. For some children, not eating may be a way to maintain some control. This can set the child and caregiver in opposition to each other. Hot and cold foods can be painful on ulcerated mucosal membranes. Substitution of high-calorie foods that the lcdhi likes and can eat should be used. DIF: Cognitive Level: Applying REF: MCS: 1394 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 17. The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse include? a. Wearing hats or scarves is preferable to a wig. b. Expose head to sunlight to stimulate hair regrowth. c. Hair may have a slightly different color or texture when it regrows. d. Regrowth of hair usually begins 12 months after chemotherapy ends. ANS: C Alopecia is a side effect of acienrtchemotherapeutic agents and cranial irradiation. When the hair regrows, it may be of a different color or texture. Children should choose the head covering they prefer. A wig should be lseected s imilar to the childs own hairstyle and color before the hair loss. The head should be protected from sunlight to avoid sunburn. The hair usually grows back within 3 to 6 months after the cessation of treatment. DIF: Cognitive Level: Applying REF: MCS: 1395 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 18. What pain management approach is most effective for a child who is having a bone marrow test? a. Relaxation techniques b. Administration of an opioid c. EMLA cream applied over site d. Conscious or unconscious sedation ANS: D Children need explanations before each procedure that is being done to them. Effective pharmacologic and nonpharmacologic measures should be used to minimize pain associated with procedures. For bone marrow aspiration, conscious or unconscious sedation should be used. Relaxation, opioids, and EMLA can be used to augment the sedation. DIF: Cognitive Level: Applying REF: MCS: 1396 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 19. The nurse is caring for a child receiving chemotherapy for leukemia. The childs granulocyte count is 600/mm3 and platelet count is 45,000/mm3. What oral care should the nurse recommend for this child? a. Rinsing mouth with water b. Daily toothbrushing and flossing c. Lemon glycerin swabs for cleansing d. Wiping teeth with moistened gauze or Toothettes ANS: B Oral care is essential for children receiving chemotherapy to prevent infections and other complications. When the childs granulocyte count is above 500/mm3 and platelet count is above 40,000/mm3, daily brushing and flossing are recommended. Rinsing the mouth with water is not effective for oral hygiene. Lemon glycerin swabs are avoided because they have a drying effect on the mucous membranes, and the lemon may irritate eroded tissue and decay the childs teeth. Wiping teeth with moistened gauze or Toothettes is recommended when the childs granulocyte count is below 500/mm3 and platelet count is below 40,000/mm3. DIF: Cognitive Level: Applying REF: MCS: 1397 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 20. What immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine b. Inactivated poliovirus vaccine c. Diphtheria, pertussis, tetanus (DPT) d. Measles, mumps, rubella (MMR) ANS: D The vaccine used for iMveMR is a l virus and can cause serious disease in immunocompromised children. The tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and can be given to immunosuppressed children. The immune response is likely to be suboptimum, so delaying vaccination is usually recommended. DIF: Cognitive Level: Analyzing REF: MCS: 1397 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 21. What description identifies the pathophysiology of leukemia? a. Increased blood viscosity b. Abnormal stimulation of the first stage of coagulation process c. Unrestricted proliferation of immature white blood cells (WBCs) d. Thrombocytopenia from an excessive destruction of platelets ANS: C Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may result secondary to the increased number of WBCs. The coagulation process is unaffected by leukemia. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow. DIF: Cognitive Level: Understanding REF: MCS: 1399 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. A child with leukemia is receiving intrathecal chemotherapy to prevent which condition? a. Infection b. Brain tumor c. Central nervous system (CNS) disease d. Drug side effects ANS: C Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS prophylactic therapy is indicated. Intrathecal chemotherapy does not prevent infection or drug side effects. A brain tumor in a child with leukemia would be a second tumor, and additional appropriate therapy would be indicated. DIF: Cognitive Level: Applying REF: MCS: 1401 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 23. A parent tells the nurse that 80% of children with the same type of leukemia as his sons have a 5-year survival. He believes that because another child on the same protocol as his son has just died, his son now has a better chance of success. What is the best response by the nurse? a. It is sad for the other family but good news for your child. b. Each child has an 80% likelihood of 5-year survival. c. The data suggest that 20% of the children in the clinic will die. There are still many hurdles for your son. d. You should avoid the grieving family because you will be benefiting from their loss. ANS: B This is a common misconception for parents. The success data are based on numerous factors, including etheffectiveness of the protocol and the childs response. These are aggregate data that apply to each child and nddo onnotthdepe success or failure in other children. The failure of one child in a protocol does not improve the success rate for other children. Although the son does face more hurdles, these are aggregate data, not isfpicect o tchlienic. I t may be difficult for this family to be supportive given their concerns about their child. Families usually form support groups in pediatric oncology settings, and support during bereavement is common. DIF: Cognitive Level: Applying REF: MCS: 1421 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 24. What is a common clinical manifestation of Hodgkin disease? a. Petechiae b. Bone and joint pain c. Painful, enlarged lymph nodes d. Nontender enlargement of lymph nodes ANS: D Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful. DIF: Cognitive Level: Understanding REF: MCS: 1403 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 25. What are the most common clinical manifestations of brain tumors in children? a. Headaches and vomiting b. Blurred vision and ataxia c. Hydrocephalus and clumsy gait d. Fever and poor fine motor control ANS: A Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Diplopia (double vision), not blurred vision, can be a presenting sign of brainstem glioma. Ataxia is a clinical manifestation of brain tumors, but headaches and vomiting are the most common. Hydrocephalus can be a presenting sign in infants when the sutures have not closed. Children at this age are usually not walking steadily. Poor fine motor coordination may be a presenting sign of astrocytoma, but headaches and vomiting are the most common presenting signs of brain tumors. DIF: Cognitive Level: Understanding REF: MCS: 1406 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 26. A 5-year-old child is being prepared for surgery to remove a brain tumor. Preparation for surgery should be based on which information? a. Removal of the tumor will stop the various signs and symptoms. b. Usually the postoperative dressing covers the entire scalp. c. He is not old enough to be concerned about his head being shaved. d. He is not old enough to understand the significance of the brain. ANS: B The child should be told what he will look and feel like after surgery. This includes the anticipated size of the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing. Some of the symptoms may be alleviated by removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia maygbreavaagted. Children should be prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin. DIF: Cognitive Level: Applying REF: MCS: 1409 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 27. Essential postoperative nursing management of a child after removal of a brain tumor includes which nursing care? a. Turning and positioning every 2 hours b. Measuring all fluid intake and output c. Changing the dressing when it becomes soiled d. Using maximum lighting to ensure accurate observations ANS: B Aftergberrayi,n sur cerebral edema is a risk. Careful monitoring is essential. All fluids, ingclud intravenous antibiotics, are included in the intake. Turning and positioning depend on the surgical procedure. When large tumors are removed, the child is usually not positioned on the operative side. The dressing is not changed. It is reinforced with gauze after the amount of drainage is marked and estimated. A quiet, dimly lit environment is optimum rto dec ease stimulation and relieve discomfort such as headaches. DIF: Cognitive Level: Applying REF: MCS: 1410 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 28. An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. What approach should the nurse implement? a. Answer questions with straightforward honesty. b. Avoid discussing the seriousness of the condition. c. Explain that although the amputation is difficult, it will cure the cancer. d. Help the adolescent accept the amputation as better than a long course of chemotherapy. ANS: A Honesty is essential to gain the childs cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so there is time for reflection about the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for craadl isurgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery. DIF: Cognitive Level: Analyzing REF: MCS: 1413 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 29. What is an important priority in dealing with the child suspected of having Wilms tumor? a. Intervening to minimize bleeding b. Monitoring temperature for infection c. Ensuring the abdomen is protected from palpation d. Teaching parents how to manage the parenteral nutrition ANS: C Wilms tumor, or nephroblastoma, is the most common malignant renal and intraabdominal tumor of childhood. The abdomen is protected, and palpation is avoided. Careful handling and bathing are essential to prevent trauma to the tumor esi.tBefore chemotherapy, the child is not myelosuppressed. Bleeding is not usually a risk. Infection is a concern after surgery and during chemotherapy, not before surgery. Parenteral therapy is not indicated before surgery. DIF: Cognitive Level: Understanding REF: MCS: 1415 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 30. The mother of an infant tells the nurse that sometimes there is a whitish glow in the pupil of his eye. The nurse should suspect which condition? a. Brain tumor b. Retinoblastoma c. Neuroblastoma d. Rhabdomyosarcoma ANS: B When the nurse examines the eye, the light will reflect off of the tumor, giving the eye a whitish appearance. This is called a cats eye reflex. Brain tumors are not lulsyuvaisible. N euroblastoma usually arises from the adrenal medulla and sympathetic nervous system. The most common presentation sites are in the abdomen, head, neck, ovirsp. eSlupraorbital ecchymosis may be present with distant metastasis. Rhabdomyosarcoma is a soft tissue tumor that idveer skeletal muscle undifferentiated cells. DIF: Cognitive Level: Understanding REF: MCS: 1418 s from TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 31. The nurse is caring for a 6-year-old child with acute lymphoblastic leukemia (ALL). The parent states, My child has a low platelet count, and we are being discharged this afternoon. What do I need to do at home? What statement is most appropriate for ethnurse to m ake? a. You should give your child aspirin instead of acetaminophen for fever or pain. b. Your child should avoid contact sports or activities that could cause bleeding. c. You should feed your child a bland, soft, moist diet for the next week. d. Your child should avoid large groups of people for the next week. ANS: B A child with a low platelet count needs to avoid activities that could cause bleeding such as playing contact sports, climbing trees, using playground equipment, or bike riding. The child should be given acetaminophen, not aspirin, for fever or pain; the child does not need to be on a soft, bland diet or avoid large groups of people because of the low platelet count. DIF: Cognitive Level: Applying REF: MCS: 1392 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 32. One pediatric oncologic emergencytiestaucmuor be occurring include what? a. Muscle cramps and tetany b. Respiratory distress and cyanosis c. Thrombocytopenia and sepsis d. Upper extremity edema and neck vein distension ANS: A ilsyssyndrome. S ymptoms that this may Risk factors for development of tumor lysis syndrome include a high white blood cell count at diagnosis, large tumor burden, sensitivity to chemotherapy, and high proliferative rate. In addition to the described metabolic abnormalities, children may develop a spectrum of clinical symptoms, including flank pain, lethargy, nausea and vomiting, muscle cramps, pruritus, tetany, and seizures. Respiratory distress and cyanosis occur with hyperleukocytosis. Thrombocytopenia and sepsis occur with disseminated intravascular coagulation. Upper extremity edema and neck vein distention occur with superior vena cava syndrome. DIF: Cognitive Level: Analyzing REF: MCS: 1386 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 33. A child has an absolute neutrophil count (ANC) of 500/mm3. The nurse should expect to be administering which pscrreibed treatment? a. Platelets b. Packed red blood cells c. Zofran (ondansetron) d. G-CSF (Neupogen) daily ANS: D G-CSF (filgrastim [Neupogen], pegfilgrastim [Neulasta]) directs granulocyte development and can decrease the duration of neutropenia following immunosuppressive therapy. G-CSF is discontinued when the ANC surpasses 10,000/mm3. DIF: Cognitive Level: Applying REF: MCS: 1391 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 34. What specific gravity of the urine is desired so that hemorrhagic cystitis is prevented? a. 1.035 b. 1.030 c. 1.025 d. 1.005 ANS: D Sterile hemorrhagic cystitis is a side effect of chemical irritation to the bladder from chemotherapy or radiotherapy. It can be prevented by a liberal oral or parenteral fluid intake (at least one and a half times the recommended daily fluid requirement). The urine should be dilute so 1.005 is the expected specific gravity. DIF: Cognitive Level: Analyzing REF: MCS: 1395 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 35. A child, age 10 years, has a neuroblastoma and is in the hospital for additional chemotherapy treatments. What laboratory values are most likely this cilhds? a. White blood cell count, 17,000/mm3; hemoglobin, 15 g/dl b. White blood cell count, 3,000/mm3; hemoglobin, 11.5 g/dl c. Platelets, 450,000/mm3; hemoglobin, 12 g/dl d. White blood cell count, 10,000/mm3; platelets, 175,000/mm3 ANS: B Chemotherapy is the mainstay of therapy for extensive local or disseminated neuroblastoma. The drugs of choice are vincristine, doxorubicin, cyclophosphamide, cisplatin, etoposide, ifosfamide, and carboplatin. These cause immunosuppression, so the laboratory values will indicate a low white blood cell count and hemoglobin. DIF: Cognitive Level: Analyzing REF: MCS: 1411 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 36. Calculate the absolute neutrophil count (ANC) for the following: WBC count of 5000 mm3; neutrophils (segs) of 10%; and nonsegmented neutrophils (bands) of 12%. a. 110/mm3 b. 500/mm3 c. 1100/mm3 d. 5000/mm3 ANS: C Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC) count by percentage of neutrophils. WBC = 1000/mm3, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7% Step 1: 10% + 12% = 22% Step 2: 0.22 5000 = 1100/mm3 ANC DIF: Cognitive Level: Applying REF: MCS: 1391 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 37. A child has been diagnosed with a Wilms tumor. What should preoperative nursing care include? a. Careful bathing and handling b. Monitoring of behavioral status c. Maintenance of strict isolation d. Administration of packed red blood cells ANS: A Careful bathing and handling are important in preventing trauma to the Wilms tumor site. DIF: Cognitive Level: Applying REF: MCS: 1416 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 38. What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy? a. Mouthwashes with plain saline b. Lemon glycerin swabs for cleansing c. Mouthwashes with hydrogen peroxide d. Swish and swallow with viscous lidocaine ANS: A Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method of cleaning the gums is to wrap a piece of gauze around a finger; soakniet ionrsali and swab the gums, palate, and inner cheek surfaces with the finger. Mouthnri apiln w ater; ses are best accomplished wthiplain water or s aline because the child cannot glaer or spit out excess fluid. Avoid agents such as lemon glycerin swabs and hydrogen peroxide because of the drying effects on the mucosa. Lidocaine should be avoided in young children. DIF: Cognitive Level: Applying REF: MCS: 1385 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 39. The nurse should expect to care for which age of child if the admitting diagnosis is retinoblastoma? a. Infant or toddler b. Preschool- or school-age child c. School-age or adolescent child d. Adolescent ANS: A The average age of the child at the time of diagnosis is 2 years, and bilateral and hereditary disease is diagnosed earlier than unilateral and nonhereditary disease. DIF: Cognitive Level: Understanding REF: MCS: 1418 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Physiological Integrity 40. Postoperative positioning for a child who has had a medulloblastoma brain tumor (infratentorial) removed should be which? a. Trendelenburg b. Head of bed elevated above heart level c. Flat on operative side with pillows behind the head d. Flat, on either side with pillows behind the back ANS: D The child with an infratentorial procedure is usually positioned flat and on either side. Pillows should be placed against the childs back, not head, to maintain the desired position. The Trendelenburg position is contraindicated in both infratentorial and supratentorial surgeries because it increases intracranial pressure and the risk of hemorrhage. DIF: Cognitive Level: Applying REF: MCS: 1410 TOP: NursoicnegssP:rImplementation MSC: Client Needs: Physiological Integrity 41. A child is receiving vincristine (Oncovin). The nurse should monitor for which side effect of this medication? a. Diarrhea b. Photosensitivity c. Constipation d. Ototoxicity ANS: A Vincristine, and to a lesser extent vinblastine, can cause various neurotoxic effects. One of the more common inceuefrfoetcotxs is severe constipation caused from decreased bowel innervation. DIF: Cognitive Level: Applying REF: MCS: 1412 TOP: NursoicnegssP:rAssessment MSC: Client eNdes: Physiologica l Integrity 42. What chemotherapeutic agent can cause an anaphylactic reaction? a. Prednisone (Deltasone) b. Vincristine (Oncovin) c. L-Asparaginase (Elspar) d. Methotrexate (Trexall) ANS: C A pnotitaelly f atal complication is anaphylaxis, especially from L-asparaginase, ebol mycin, cisplatin, and etoposide (VP-16). DIF: Cognitive Level: Understanding REF: MCS: 1383 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 43. A child with cancer being treated with chemotherapy is receiving a platelet transfusion. The nurse understands that the transfused platelets should survive the body for how many days? a. 1 to 3 days b. 4 to 6 days c. 7 to 9 days d. 10 to 12 days ANS: A Transfused platelets generally survive in the body for 1 to 3 days. The peak effect is reached in about 1 hour and decreased by half in 24 hours. DIF: Cognitive Level: Understanding REF: MCS: 1392 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 44. Daily toothbrushing and flossing can be encouraged for the child on chemotherapy when the platelet count is above which? a. 10,000/mm3 b. 20,000/mm3 c. 30,000/mm3 d. 40,000/mm3 ANS: D Daily toothbrushing and flossing are encouraged in children with platelet counts above 40,000/mm3. DIF: Cognitive Level: Analyzing REF: MCS: 1397 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 45. A parent of a hospitalized child on chemotherapy asks the nurse if a sibling of the hospitalized child should receive the varicella vaccination. The nurse should give which response? a. The sibling can get a varicella vaccination. b. The sibling should not get a varicella vaccination. c. The sibling should wait until the child is finished with chemotherapy. d. The sibling should get varicella-zoster immune globulin if exposed to chickenpox. ANS: A Siblings and ioltyhemrefmambers can r eceive the live measles, mumps, and rubella vaccine and the varicella vaccine without risk to the child who is immunosuppressed. DIF: Cognitive Level: Applying REF: MCS: 1397 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 46. The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of neuroblastoma. What finding in the urine is expected with neuroblastomas? a. Ketones b. Catecholamines c. Red blood cells d. Excessive white blood cells ANS: B Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain, excrete the catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines is detected in approximately 95% of children with adrenal or sympathetic tumors. DIF: Cognitive Level: Analyzing REF: MCS: 1412 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 47. A child with osteosarcoma is experiencing phantom limb pain after an amputation. What prescribed medication is effective for tsehromrt- phantom pain relief? a. Phenytoin (Dilantin) b. Gabapentin (Neurontin) c. Valproic Acid (Depakote) d. Phenobarbital (Phenobarbital) ANS: B A recent Cochrane review reported that various medications have been used for phantom limb pain but complete pain relief has been unsuccessful. Morphine, gabapentin, and ketamine are effective for short-term pain relief. DIF: Cognitive Level: Applying REF: MCS: 1414 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and oncology clinic. What cardinal signs of cancer in children should the nurse make the new nurse aware of? (Select all that apply.) a. Sudden tendency to bruise easily b. Transitory, generalized pain c. Frequent headaches d. Excessive, rapid weight gain e. Gradual, steady fever f. Unexplained loss of energy ANS: A, C, F The cardinal signs of cancer inlcuhdieldaresnudindcen t endency to bruise easily; efrquent headaches, often with vomiting; and an unexplained loss of energy. Other cardinal signs include persistent, localized pain; excessive, rapid weight loss; and a prolonged, unexplained fever. DIF: Cognitive Level: Applying REF: MCS: 1381 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 2. A child on chemotherapy has developed rectal ulcers. What interventions should the nurse teach to the child and parents to relieve cthoemdfiosrt of rectal ulcers? (Select all that apply.) a. Warm sitz baths b. Use of stool softeners c. Record bowel movements d. Use of an opioid for discomfort e. Occlusive ointment applied to the area ANS: A, B, C, E If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement, and an occlusive ointment applied to the ulcerated area promote healing; the use of stool softeners is necessary to prevent tfhuerr d iscomfort. Parents should record bowel movements because the child may voluntarily avoid defecation to prevent discomfort. Opioids would cause increased constipation. DIF: Cognitive Level: Applying REF: MCS: 1394 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 3. What are favorable prognostic criteria for eacluytmphoblastic leukemia? (Select all that apply.) a. Male gender b. CALLA positive c. Early preB cell d. 2 to 10 years of age e. Leukocyte count ?7?50,000/mm3 ANS: B, C, D Favorable prognostic criteria for acute lymphoblastic leukemia include CALLA positive, early preB cell, and age 2 to 10 years. Leukocyte count less, not greater, than 50,000/mm3 and female, not male, gender are favorable prognostic criteria. DIF: Cognitive Level: Analyzing REF: MCS: 1400 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 4. The nurse should teach the family that which residual disabilities can occur for a child being treated for a brain tumor? (Select all that apply.) a. Ataxia b. Anorexia c. Dysphagia d. Sensory deficits e. Crania nerve palsies ANS: A, C, D, E Even with children who are long-term survivors after treatment for a brain tumor, reidsual disabilities, such as short stature, cranial nerve palsies, sensory defects, motor albintioersm (especially ataxia), intellectual deficits, dysphagia, dysgraphia, and behavioral problems, may occur. Anorexia is not a residual disability. DIF: Cognitive Level: Applying REF: MCS: 1411 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is caring for a child with retinoblastoma that was treated with an enucleation. What interventions should the nurse plan for care of an keyete asfotecr enuc leation? (Select all that apply.) a. Clean the prosthesis. b. Change the eye pad daily. c. Keep the opposite eye covered initially. d. Irrigate the socket daily with a prescribed solution. e. Apply a prescribed antibiotic ointment after irrigation. ANS: B, D, E Care of the socket is minimal and easily accomplished. The wound itself is clean and has little or no drainage. If an antibiotic ointment is prescribed, it is applied in a thin line on the surface of the tissues of the socket. To cleanse the site, an irrigating solution may be ordered and is instilled daily or more frequently if necessary before application of the antibiotic ointment. The dressing consists of an eye pad changed daily. The prosthesis is not placed until the socket has healed. The opposite eye is not covered. DIF: Cognitive Level: Applying REF: MCS: 1420 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. What guidelines should the nurse follow when handling chemotherapeutic agents? (Select all that apply.) a. Use clean technique. b. Prepare medications in a safety cabinet. c. Wear gloves designed for handling chemotherapy. d. Wear face and eye protection when splashing is possible. e. Discard gloves and protective clothing in a special container. ANS: B, C, D, E Safe handling of ochtheemrapeutic agents includes preparing medications in a safety cabinet, wearing gloves designed for handling chemotherapy, wearing face and eye protection when splashing isblpeo, sasnd discarding gloves and protective clothing in a special container. Aseptic, not clean, technique should be used. DIF: Cognitive Level: Applying REF: MCS: 1384 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 7. What strategies should the nurse implement to increase nutritional intake for the child receiving chemotherapy? (Select all that apply.) a. Allow the child any food tolerated. b. Fortify foods with nutritious supplements. c. Allow the child to be involved in food selection. d. Encourage the parents to place pressure on the importance of eating. e. Encourage the child to eat favorite foods during infusion of chemotherapy medications. ANS: A, B, C To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the child any food tolerated, fortify foods with nutritious supplements, and allow the child to be involved in food selection. The parents should be encouraged to reduce pressure placed on eating. Some children develop aversions to certain foods if they are eaten during chemotherapy. It is best to refrain from offering the childs vfaorite f oods while the child is receiving chemotherapy. DIF: Cognitive Level: Applying REF: MCS: 1389 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity COMPLETION 1. A health care provider prescribes ondansetron (Zofran) 0.15 mg/kg intravenously (IV) 30 minutes before chemotherapy for a child with acute lymphoblastic leukemia. The child weighs 22 kg. The medication label states: Ondansetron (Zofran) 2 mg/1 ml. The nurse prepares to administer the .dHose ow many milliliters will tehpe nurs epr are to administer the ed?osF ill in the blank. Round your answer to one decimal place. ANS: 1.7 Follow the formula for dosage calculation. 22 0.15 = 3.3 mg as the dose Desired Volume = ml per dose Available 3.3 mg 1 ml = 1.65 ml round to 1.7 ml 2 mg DIF: Cognitive Level: Applying REF: MCS: 1393 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The health care provider prescribes ceftazidime (Fortaz) 75 mg per tirnavenous piggyback (IVPB) every 8 hours for a child with cancer admitted with fever and neutropenia. The pharmacy sends the medication to the unit in a 50-ml bag with cdtiiroens to run the medication over 30 minutes. What milliliters per hour will the nurse tsethe intravenous pump to run the medication over 30 minutes? Fill in the blank and record your answer in a whole number. ANS: 100 Perform the calculation. 50 ml 60 minutes = 100 ml/hr 30 minutes DIF: Cognitive Level: Applying REF: MCS: 1390 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The health care provider prescribes vancomycin 200 mg per intravenous piggyback (IVPB) every 6 hours for a child with cancer admitted to the hospital for fever and neutropenia. The pharmacy sends the medication to the unit in a 240-ml bag with cdtiiroens to run the medication over 120 minutes. What milliliters per hour will the nurse set trhaeviennous pump to run the medication over 120 minutes? Fill in the blank and record your answer in a whole number. ANS: 120 Perform the calculation. Convert the minutes to hours = 120/60 = 2 hours 240 ml = 120 ml/hr 2 hours DIF: Cognitive Level: Applying REF: MCS: 1390 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. A health care provider prescribes Osmitrol (mannitol) 0.25 g/kg intravenously (IV) every 6 hours for a child taefr aibn turamor remova l. The child weighs 20 kg. The medication label states: Osmitrol (Mannitol) 250 mg/1 ml. The nurse prepares to administer the dose. How many milliliters will the enuprrsepare to a dminister the dose? Fill in the nblka. Record your answer in a whole number. ANS: 20 Calculate the dose. 0.25 g 20 = 5 g convert to mg = 5000 mg Follow the formula for dosage calculation. Desired Volume = ml per dose Available 5000 mg 1 ml = 20 ml 250 mg DIF: Cognitive Level: Applying REF: MCS: 1410 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 5. Calculate the absolute neutrophil count for a child with a WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10%. Record your answer below in a whole number. ANS: 600 Perform the calculation Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC) count by percentage of neutrophils. WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10% Step 1: 10% + 10% = 20% Step 2: 0.2 3000 = 600/mm3 ANC DIF: Cognitive Level: Applying REF: MCS: 1391 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 6. Calculate the absolute neutrophil count for a child with a WBC = 6000/mm3, neutrophils = 18%, and nonsegmented neutrophils (bands) = 20%. Record your answer below in a whole number. ANS: 2280 Perform the calculation Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC) count by percentage of neutrophils. WBC = 6000/mm3, neutrophils = 18%, nonsegmented neutrophils (bands) = 20% Step 1: 18% + 20% = 38% Step 2: 0.38 6000 = 2280/mm3 ANC DIF: Cognitive Level: Applying REF: MCS: 1391 TOP: Nursing Process: Evaluation MSC: Client eNdes: Physiologica l Integrity 7. Calculate the absolute neutrophil count for a child with a WBC = 10,000/mm3, neutrophils = 25%, and nonsegmented neutrophils (bands) = 22%. Record your answer in a whole number. ANS: 4700 Perform the calculation Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC) count by percentage of neutrophils. WBC = 10,000/mm3, neutrophils = 25%, and nonsegmented neutrophils (bands) = 22% Step 1: 25% + 22% = 47% Step 2: 0.47 10,000 = 4700/mm3 ANC DIF: Cognitive Level: Applying REF: MCS: 1391 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 8. Calculate the absolute neutrophil count for a child with a WBC = 15,000/mm3, neutrophils = 29%, and nonsegmented neutrophils (bands) = 29%. Record your answer in a whole number. ANS: 8700 Perform the calculation Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC) count by percentage of neutrophils. WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10% Step 1: 29% + 29% = 58% Step 2: 0.58 15,000 = 8700/mm3 ANC Chapter 30.The Child with Cerebral Dysfunction MULTIPLE CHOICE 1. An injury to which part of the brain will cause a coma? a. Brainstem b. Cerebrum c. Cerebellum d. Occipital lobe ANS: A Injury to the brainstem results in stupor and coma. Signs of damage to the cerebrum are specific to the involved area. Individuals with frontal lobe injury may have impaired memory, personality changes, or altered intellectual functioning. Individuals with damage to the cerebellum have difficulties with coordination of muscle movements, including ataxia and nystagmus. Impaired vision and functional blindness result from injury to the occipital lobe. DIF: Cognitive Level: Understanding REF: MCS: 1425 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. What finding is a clinical manifestation of rineacsed i ntracranial pressure (ICP) hinilcdren? a. Low-pitched cry b. Sunken fontanel c. Diplopia, blurred vision d. Increased blood pressure ANS: C Diplopia and blurred vision are signs of increased ICP in children. A high-pitched cry and a tense or bulging fontanel are characteristic of increased ICP. Increased blood pressure, common in adults, is rarely seen in children. DIF: Cognitive Level: Analyzing REF: MCS: 1428 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 3. What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called? a. Twitching b. Spasticity c. Choreiform movements d. Associated movements ANS: C Quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation are called choreiform movements. Twitching is defined as spasmodic movements of short duration. Spasticity lios nthgedpraond steady contraction of a muscle characterized by clonus (alternating relaxation and contraction of tmheuscle) and ex aggerated reflexes. Associated movements are the voluntary movement of one muscle accompanied by the involuntary movement of another muscle. DIF: Cognitive Level: Understanding REF: MCS: 1430 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. What term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state describes trhmeapnent loss of function of the cerebral cortex. DIF: Cognitive Level: Understanding REF: MCS: 1431 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. What term is used to describe a childs level of consciousness when the child is arousable with stimulation? a. Stupor b. Confusion c. Obtundation d. Disorientation ANS: C Obtundation describes a level of consciousness in which the child is arousable with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place. DIF: Cognitive Level: Understanding REF: MCS: 1431 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this? a. Eye trauma b. Brain death c. Severe brainstem damage d. Neurosurgical emergency ANS: D The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. One fixed and dilated pupil is not suggestive of brain death. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. DIF: Cognitive Level: Analyzing REF: MCS: 1433 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. The nurse is caring for a child with seehveeard trauma after a car a ccident. What is an ominous sign that often precedes death? a. Delirium b. Papilledema c. Flexion posturing d. Periodic or irregular breathing ANS: D Periroredgiculoarr ibreathing is an ominous nsigof brainstem (especially medullary) dysfunction tehcaetdoefstecnomprplete apnea. Delirium is a state of mental confusion and excitement kmeadr by d isorientation for mti e and place. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Flexion posturing is seen with severe dysfunction of the cerebral cortex or of the corticospinal tracts above the brainstem. DIF: Cognitive Level: Applying REF: MCS: 1429 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 8. What test is never performed on a child who is awake? a. Dolls head maneuver b. Oculovestibular response c. Assessment of pyramidal tract lesions d. Funduscopic examination for papilledema ANS: B The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on an awake child or one who has a ruptured tympanic membrane. Tdohlels head m aneuver, assessment of pyramidal tract lesions, and funduscopic examination for papilledema are not considered painful and can be performed on awake children. DIF: Cognitive Level: Analyzing REF: MCS: 1433 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 9. The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings? a. Neurologic health b. Severe brain damage c. Decorticate posturing d. Decerebrate posturing ANS: A Moro, tonic neck, tahnddrawwial reflexes are three reflexes that are present in a healthy 2- month-old infant and are expected in this age group. DIF: Cognitive Level: Applying REF: MCS: 1434 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 10. The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral function. The nurse should include what statement in preparing the child? a. The scan will not hurt. b. Pain medication will be given. c. You will be able to move once the equipment is in place. d. Unfortunately no one can remain in the room with you during the test. ANS: A For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. The child will not be allowed to move and will be immobilized. Someone is able to remain with the child during the procedure. DIF: Cognitive Level: Applying REF: MCS: 1435 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 11. What is a nursing intervention to reduce the srik of increasing intracranial pressure (ICP) in an unconscious child? a. Suction the child frequently. b. Turn the childs head side to side every hour. c. Provide environmental stimulation. d. Avoid activities that cause pain or crying. ANS: D Unrelieved pain, crying, and emotional stress all contribute to increasing the ICP. Disturbing procedures shouldrbrieedcaou t at the same time as therapies that reduce ICP, such as sedation. Suctioning yis tpooleorralted by children. Whe n necessary, it is preceded by hyperventilation with 100% oxygen. Turning the head side to side is contraindicated for fear of compressing the jugular vein. This would block the flow of blood from the brain, raising ICP. Nontherapeutic touch and environmental stimulation increase ICP. Minimizing both touch and environmental stimuli noise reduces ICP. DIF: Cognitive Level: Applying REF: MCS: 1439 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 12. What nursing intervention is appropriate when caring for an unconscious child? a. Avoid using narcotics or sedatives to provide comfort and pain relief. b. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP). c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are contraindicated. ANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. Narcotics and sedatives should be used as necessary to reduce pain and anxiety, which can increase ICP. The childs position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Antipyretics are the method of choice for fever reduction. DIF: Cognitive Level: Applying REF: MCS: 1439 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 13. What statement siscrdieptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient and reversible neuronal dysfunction. d. It is a slight lesion that develops remote from the site of trauma. ANS: C A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages on the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an accelerationdeceleration injury. DIF: Cognitive Level: Understanding REF: MCS: 1444 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 14. What statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region. ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. DIF: Cognitive Level: Understanding REF: MCS: 1446 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 15. A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse immediately assesses airway, breathing, and circulation. What should be the next nursing action? a. Place the child on his side. b. Take the childs blood pressure. c. Stabilize the childs neck and spine. d. Check the childs scalp and back for bleeding. ANS: C After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The childs position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. A less urgent but important assessment is inspection of the scalp for bleeding. DIF: Cognitive Level: Applying REF: MCS: 1448 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 16. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The childs level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action? a. Explain that analgesia is contraindicated with a head injury. b. Have the parents describe the childs previous experiences with pain. c. Consult with a practitioner about what analgesia can be safely administered. d. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert. ANS: C A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoidlcicotnbfe tween the necessity to monitor the childs neurologic status and to promote comfort and relieve anxiety. Analgesia can be safely used in individuals who have sustained head injuries. The childs previous experiences with pain should be obtained as part of the assessment, but ubseeca of the severity of the injury, analgesia should be provided as soon as possible.lAgensaia can d ecrease anxiety atanndt resul intracranial pressure. DIF: Cognitive Level: Applying REF: MCS: 1450 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity increased 17. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness ANS: D The most important nursing observation is assessment of the childs level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage. DIF: Cognitive Level: Analyzing REF: MCS: 1451 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 18. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mr. oWthheat si gn or msymispto considered a manifestation of postconcussion syndrome and does not necessitate medical attention? a. Vomiting b. Blurred vision c. Behavioral changes d. Temporary loss of consciousness ANS: C The parents are advised of probable posttraumatic symptoms that may cbteedex. pe These include behavioral changes, sleep disturbances, emotional lability, and alterations in school performance. If the child is vomiting, has blurred vision, or has temporary loss of consciousness, she should be seen for evaluation. DIF: Cognitive Level: Understanding REF: MCS: 1451 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 19. An 18-month-old child is brought to the emergency department after being found unconscious in the family pool. What does the nurse identify as the primary problem in drowning incidents? a. Hypoxia b. Aspiration c. Hypothermia d. Electrolyte imbalance ANS: A Hypoxia is the apryimpr oblem because it results in global cell damage, with fdeirfent cells tolerating variable lengths of anoxia. Neurons sustain irreversible damage after 4 to 6 minutes of submersion. Severe neurologic damage occurs from hypoxia in 3 to 6 minutes. Aspiration of fluid does occur, resulting in pulmonary edema, atelectasis, airway spasm, and pneumonitis, which complicate the anoxia. Hypothermia occurs rapidly, except in hot tubs. cEtlreolyte imbalances do result, but they are not a major cause of morbidity and mortality. DIF: Cognitive Level: Understanding REF: MCS: 1453 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 20. The mother of a 1-month-old infant tells the nurse she rwieosr tha t her baby will get meningitis like the childs younger brother had when he was an infant. The nurse should base a response on which information? a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available. ANS: D H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains raioseus illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately traesaetesd. Tche leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms. DIF: Cognitive Level: Applying REF: MCS: 1454 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 21. A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will begin when? a. After the diagnosis is confirmed b. When the medication is received from the pharmacy c. After the childs fluid and electrolyte balance is stabilized d. As soon as the practitioner is notified of the culture results ANS: B Antimicrobial therapy is begun as soon as a presumptive diagnosis is made. The choice of drug is based on the most likely infective agent. Drug ychboeice ma adjusted when the culture results are obtained. Waiting for culture results to begin therapy increases the risk of neurologic damage. Although fluid and electrolyte balance is important, there is no indication that this child is unstable. Antibiotic therapy would be a priority intervention. DIF: Cognitive Level: Analyzing REF: MCS: 1454 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. The nurse is planning care for a school-age child with tbearcial meningitis. W hat intervention should be included? a. Keep environmental stimuli to a minimum. b. Have the child move her head from side to side at least every 2 hours. c. Avoid giving pain medications that could dull sensorium. d. Measure head circumference to assess developing complications. ANS: A The room is kept as quiet as possible and environmental stimuli are kept to a minimum. Most children hwimt eningitis a re nsesitive to noi se, bright lights, and other external stimuli. The nuchal rigidity associated with meningitis would make moving the head dfreom si to side a painful intervention. If pain is present, the child should be treated appropriately. Failure to treat can cause increased rinact ranial pr essure. Initshage group, the head circumference does not change. Signs of increased intracranial pressure would need to be assessed. DIF: Cognitive Level: Applying REF: MCS: 1458 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 23. A young childs rpa ents call the nurse after their child is bitten by a raccoon in the woods. The nurses recommendation should be based on what knowledge? a. Antirabies prophylaxis must be initiated immediately. b. The child should be hospitalized for close observation. c. No treatment is necessary if thorough wound cleaning is done. d. Antirabies prophylaxis must be initiated as soon as clinical manifestations appear. ANS: A Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immunoglobulin (HRIG) as soon as possible. Hospitalization is not necessary. The wound cleansing, passive immunization, and immunoglobulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine. DIF: Cognitive Level: Applying REF: MCS: 1462 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 24. What intervention should be beneficial in reducing the risk of Reye syndrome? a. Immunization nagstait he disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin for children with varicella or those suspected of having influenza ANS: D Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, eitherivcealrla or i nfluenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so use of aspirin is avoided. No immunization currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or bacterial meningitis. DIF: Cognitive Level: Understanding REF: MCS: 1463 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 25. What term refers to seizures that involve both hemispheres of the brain? a. Absence b. Acquired c. Generalized d. Complex partial ANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Absence seizures have a sudden onset and are characterized by a brief loss of consciousness, a blank stare, and automatisms. Acquired seizure disorder is a result of a brain injury from a variety of factors; it is not a term that labels the type of iszeure. C omplex partial seizures are the most common seizures. They may begin with an aura and be manifested as repetitive involuntary activities without purpose, carried out in a dreamy state. DIF: Cognitive Level: Understanding REF: MCS: 1465 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 26. What is the initial clinical manifestation of generalized seizures? a. Confusion b. Feeling frightened c. Loss of consciousness d. Seeing flashing lights ANS: C Loss of consciousness is a frequent eonccerirn ge neralized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure. DIF: Cognitive Level: Understanding REF: MCS: 1466 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. What type of seizure may be difficult to detect? a. Absence b. Generalized c. Simple partial d. Complex partial ANS: A Absence seizures may go unrecognized because little change occurs in the childs behavior during the seizure. Generalized, psilme partial, and com plex partial all have clinical manifestations that are observable. DIF: Cognitive Level: Understanding REF: MCS: 1468 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 28. What is important to incorporate in the plan of care for a child who is experiencing a seizure? a. Describe and record the seizure activity observed. b. Suction the child during a seizure to prevent aspiration. c. Place a tongue blade between the teeth if they become clenched. d. Restrain the child when seizures occur to prevent bodily harm. ANS: A When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child is not suctioned during the seizure. If possible, the child should be placed on the side, facilitating drainage to prevent aspiration. DIF: Cognitive Level: Applying REF: MCS: 1437 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 29. A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school that lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion occurs. What is the most appropriate initial action by the school nurse? a. Stay with child and have someone else call emergency medical services (EMS). b. Notify the parent and regular practitioner. c. Notify the parent that the child should go home. d. Stay with the child, offering calm reassurance. ANS: A Because this is the childs first seizure and it lasted more than 5 minutes, EMS should be called to transport the child, and evaluation should be performed as soon as possible. The nurse should stay with the recovering child while someone else notifies EMS. DIF: Cognitive Level: Applying REF: MCS: 1478 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 30. A child has been seizure free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. How should the nurse respond? a. Medications can be discontinued at this time. b. The child will need to take the drugs for 5 years after the last seizure. c. A step-wise approach will be used to reduce the dosage gradually. d. Seizure disorders are a lifelong problem. Medications cannot be discontinued. ANS: C A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure free for s2. yMeaerd ications must be gradually reduced tonmimi ize the recurrence of seizures. The risk of rerecnu discontinuation. ce is greatest within 6 months after DIF: Cognitive Level: Applying REF: MCS: 1478 TOP: Nursing Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 31. A young adolescent experiences infrequent migraine episodes. What pharmacologic intervi ent on is most likely to be prescribed? a. Opioid b. Lorazepam c. Ergotamine d. Sumatriptan ANS: D Sumatriptan is a serotonin agonist at specific vascular serotonin receptor sites and causes vasoconstriction in large intracranial arteries. Opioids are used infrequently because they rarely work on the mechanism of pain. Lorazepam is a benzodiazepine that acts as an anxiolytic and sedative. It is not indicated for treatment of migraine episodes. Ergotamine, an -adrenergic blocker, is used for adult vascular headaches, but it is not used in adolescents because of the side effects. DIF: Cognitive Level: Understanding REF: MCS: 1483 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 32. The nurse is teaching tphaerents of a 3-year-old child who has been diagnosed with tonic- clonic seizures. What statement bpyartehnet sho uld indicate a correct understanding of the teaching? a. I should attempt to restrain my child during a seizure. b. My child will need to avoid contact sports until adulthood. c. I should place a pillow under my childs head during a seizure. d. My child will need to be taken to the emergency department [ED] after each seizure. ANS: C Parents should try to place a pillow or folded blanket under the childs head for protection. The parent should not try to restrain the child during the seizure. The child does not need to go to the ED with each seizures; the nurse can teach parents certain ictreria for nwht e heir cdhwilould need to be seen. Discussing what will happen in adulthood is not appropriate at this time. DIF: Cognitive Level: Analyzing REF: MCS: 1468 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 33. The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the childs care plan? a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline. b. Maintain an active, stimulating environment. c. Perform chest percussion and suctioning every 1 to 2 hours. d. Perform active range of motion and nontherapeutic touch every 8 hours. ANS: A Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP. DIF: Cognitive Level: Applying REF: MCS: 1439 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 34. What clinical manifestations suggest hydrocephalus in an infant? a. Closed fontanel and high-pitched cry b. Bulging fontanel and dilated scalp veins c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure ANS: B Bulging afonnetls, d ilated scalpnvse,ian dastedasru tures are clinical manifestations of hydrocephalus in neonates. A closed fontanel, high-pitched cry, constant low-pitched cry, restlessness, a depressed fontanel, and edaescerd blood pressure are not icnlical m anifestations of hydrocephalus, but all should be referred for evaluation. DIF: Cognitive Level: Understanding REF: MCS: 1482 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 35. A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurses response should be based on which knowledge? a. It can be diagnosed only after birth. b. It can be diagnosed by chromosome studies. c. It can be diagnosed with fetal ultrasonography. d. It can be diagnosed by measuring the lecithin-to-sphingomyelin ratio. ANS: C Hydrocephalus can be diagnosed by fetal ultrasonography as early as 14 weeks of gestation. Most incidents of hydrocephalus are not chromosomal in origin. The lecithin-to-sphingomyelin ratio can be used to determine fetal lung maturity. DIF: Cognitive Level: Analyzing REF: MCS: 1486 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 36. A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What is a common reason for elective revision of this shunt? a. Meningitis b. Gastrointestinal upset c. Hydrocephalus resolution d. Growth of the child since the initial shunting ANS: D An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the childs growth. Meningitis would require an emergent replacement or revision of the shunt. Gastrointestinal upset alone would not indicate the need for shunt revision. Noncommunicating hydrocephalus will not resolve without surgical intervention. DIF: Cognitive Level: Understanding REF: MCS: 1487 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 37. What is a priority of care when a child has an external ventricular drain (EVD)? a. Irrigation of drain to maintain flow b. As-needed dressing changes if dressing becomes wet c. Frequent assessment of amount and color of drainage d. Maintaining the EVD below the level of the childs head ANS: C The EVD is inserted into the childs ventricle. Frequent assessment cisesnseary t oedremtine amount of drainage and whether an infection is present. The EVD is a closed system and is not opened for irrigation. Antibiotics may be administered through the drain, but this is usually done by the neuropractitioner. The dressing is not changed. If it becomes wet, then the practitioner should be notified that cerebrospinal fluid (CSF) may be leaking. Unless ordered, maintaining the EVD below the level of the childs head position will create too much pressure and potentially drain too much CSF. DIF: Cognitive Level: Understanding REF: MCS: 1438 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 38. The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. What issues should be addressed? a. Most childhood activities must be restricted. b. Cognitive impairment is to be expected with hydrocephalus. c. Wearing head protection is essential until the child reaches adulthood. d. Shunt malfunction or infection requires immediate treatment. ANS: D Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately. Limits should be appropriate to the childs developmental age. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed. DIF: Cognitive Level: Applying REF: MCS: 1487 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 39. A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary? a. Tachycardia b. Gastrointestinal upset c. Hypotension d. Alteration in level of consciousness ANS: D In older children, who are usually admitted to the hospital for elective or emergency shunt revision, the most valuable indicators of increasing intracranial pressure are an alteration in the childs level of consciousness, complaint of headache, and changes in interaction with the environment. DIF: Cognitive Level: Analyzing REF: MCS: 1489 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 40. Afterca toni -clonic seizure, what symptoms should the nurse expect the child to experience? a. Diarrhea and abdominal discomfort b. Irritability and hunger c. Lethargy and confusion d. Nervousness and excitability ANS: C In the tpaolsptihcase, a fter a tonic-clonic seizure, the child may remain semiconscious and difficult to arouse. The average duration of the postictal phase is usually 30 minutes. The child may remain confused or sleep for asel vheoru rs. He or she may have mild irmmpeant of fine motor movements. The child may have visual and speech difficulties and may vomit or complain of headache. DIF: Cognitive Level: Analyzing REF: MCS: 1467 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 41. What is the antiepileptic medication that requires monitoring of vitamin D and folic acid? a. Topiramate (Topamax) b. Valproic acid (Depakene) c. Gabapentin (Neurontin) d. Phenobarbital (Luminal) ANS: D Children taking phenobarbital or phenytoin shouldirveeceadequate vitamin D and folic acid because deficiencies of both have been associated with these drugs. DIF: Cognitive Level: Analyzing REF: MCS: 1479 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 42. A 2-year-old child starts to have a tonic-clonic seizure. The childs jaws are clamped. What is the most important nursing action at this eti?m a. Place a padded tongue blade between the childs jaws. b. Stay with the child and observe his respiratory status. c. Prepare the suction equipment. d. Restrain the child to prevent injury. ANS: B It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The nurse must remain calm, stay with the child, and prevent the child from sustaining any harm during the seizure. The nurse should not move or forcefully restrain the child during a tonic- clonic seizure and should not place a solid object between the teeth. Suctioning may be needed but not until the seizure has ended. DIF: Cognitive Level: Applying REF: MCS: 1478 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 43. A child has been admitted with status epilepticus. An emergency medication has been ordered. What medication should the nurse expect to be prescribed? a. Lorazepam (Ativan) b. Phenytoin (Dilantin) c. Topiramate (Topamax) d. Ethosuximide (Zarontin) ANS: A For in-hospital management of status epilepticus, intravenous diazepam or loratizveapna)m (A is the first-line drug of choice. Lorazepam is the preferred agent because of its rapid onset (25 minutes) and long half-life (1224 hours) with few side effects. DIF: Cognitive Level: Analyzing REF: MCS: 1473 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 44. A child is on phenytoin (Dilantin). What should the nurse encourage? a. Fluid restriction b. Good dental hygiene c. A decrease in vitamin D intake d. Taking the medication with milk ANS: B Chronic treatment with phenytoin may cause gum hypertrophy. Children taking phenobarbital or phenytoin should receive adequate vitamin D and folic acid because deficiencies of both have been associated with these drugs. The medication should not be taken with milk, and fluids should be encouraged, not restricted. DIF: Cognitive Level: Applying REF: MCS: 1472 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 45. A child has a seizure disorder. What test should be done to gather the most specific information about the type of seizure the child is having? a. Sleep study b. Skull radiography c. Serum electrolytes d. Electroencephalogram (EEG) ANS: D An EEG is obtained for all children with seizures and is the most useful tool for evaluating a seizure disorder. The EEG confirms the presence of abnormal electrical discharges and provides information on the seizure type and the focus. The EEG is carried out under varying conditionswith the child asleep, awake, awake with provocative stimulation (flashing lights, noise), and hyperventilating. Stimulation may elicit abnormal electrical activity, which is recorded on the EEG. Various seizure types produce characteristic EEG patterns: high-voltage spike discharges are seen in tonic-clonic seizures, with abnormal patterns in the intervals between seizures; a three-per-second spike and wave pattern is observed in an absence seizure; and absence of electrical activity in aneasrtesaasluagrge lesion, such as an abscess or subdural collection of fluid. DIF: Cognitive Level: Analyzing REF: MCS: 1470 TOP: NursoicnegssP:rAssessment lMieSnCt : C Needs: Physiological Integrity 46. A child develops syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a complication to meningitis. What action should be verified before implementing? a. Forcing fluids b. Daily weights with strict input and output (I and O) c. Strict monitoring of urine volume and specific gravity d. Close observation for signs of increasing cerebral edema ANS: A The tmreeant of SIADH cisotns so f fluid restriction until serum electrolytes and osmolality return to normal levels. SIADH often occurs in children who have meningitis. Monitoring weights, keeping I and O and specific gravity of urine, and observing for signs of increasing cerebral edema are all part of the nursing care for a child with SIADH. DIF: Cognitive Level: Applying REF: MCS: 1440 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 47. When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised if a week ago the child had recovered from what? a. Measles b. Influenza c. Meningitis d. Hepatitis ANS: B The etiology of Reye syndrome is not well understood, but most cases follow a common viral illness, typically influenza or varicella. DIF: Cognitive Level: Analyzing REF: MCS: 1462 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 48. If an intramuscular (IM) injection is administered to a child who has Reye syndrome, the nurse should monitor for what? a. Bleeding b. Infection c. Poor absorption d. Itching at the injection site ANS: A The nurse should watch for bleeding from the site. Because of related liver dysfunction with Reye syndrome, laboratory studies, such as prolonged bleeding time, should be monitored to determine impaired coagulation. DIF: Cognitive Level: Applying REF: MCS: 1463 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 49. A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very irritable with a temperature of 102 F. What should the nurses care plan include? a. Observing the childs voluntary movement b. Checking the Babinski reflex every 4 hours c. Checking the Brudzinski reflex every 1 hour d. Assessing the level of consciousness (LOC) and vital signs every 2 hours ANS: D Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is carried out at frequent intervals on a child with meningitis. The nurse should avoid actions that cause pain or increase discomfort, suchfatis li ng the childs head, so the Brudzinski reflex should not be checked hourly. Checking the Babinski reflex or childs voluntary movements will not help with assessing the childs status. DIF: Cognitive Level: Applying REF: MCS: 1459 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 50. A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse expects which trsesfuolr the cerebrospinal fluid that can confirm the diagnosis of meningitis? a. WBCs; glucose b. RBCs; normal WBCs c. glucose; normal RBCs d. Normal RBCs; normal glucose ANS: A A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured and samples are obtained for culture, Gram stain, blood cell count, and determination of glucose and protein content. The findings are usually diagnostic. The patient generally has an elevated white blood cell count, often predominantly polymorphonuclear leukocytes. The glucose level is reduced, generally in proportion to the duration and severity of the infection. DIF: Cognitive Level: Analyzing REF: MCS: 1457 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.) a. High-pitched cry b. Poor feeding c. Setting-sun sign d. Sunken fontanel e. Distended scalp veins f. Decreased head circumference ANS: A, B, C, E Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. The infant would have a tense, bulging fontanel and an increased head circumference. DIF: Cognitive Level: Applying REF: MCS: 1428 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. The nurse is caring for a child with irneacsed i ntracranial epsrsure (ICP). What interventions should the nurse plan for this child? (Select all .t)hat apply a. Avoid jarring the bed. b. Keep the room brightly lit. c. Keep the bed in a flat position. d. Administer prescribed stool softeners. e. Administer a prescribed antiemetic for nausea. ANS: A, D, E Other measures to relieve discomfort for a child with ICP include providing a quiet, dimly lit environment; limiting visitors; preventing any sudden, jarring movement, such as banging into the bed; and preventing an increase in ICP. The latter is most effectively achieved by proper positioning and prevention of straining, such as during coughing, vomiting, or defecating. An antiemetic should be administered to prevent vomiting, and stool softeners should be prescribed to prevent straining with bowel movements. The head of the bed should be elevated 15 to 30 degrees. DIF: Cognitive Level: Applying REF: MCS: 1438 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 3. The nurse is preparing to admit a 5-year-old with an epidural hemorrhage. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Headache b. Vomiting c. Irritability d. Cephalhematoma e. Pallor with anemia ANS: A, B, C The classic clinical picture of an epidural hemorrhage is a lucid interval (momentary unconsciousness) followed by a normal period for several hours, and then lethargy or coma due to blood accumulation in the epidural space and compression of the brain. The child may be seen with varying degrees of impaired consciousness depending on the severity of the traumatic injury. Common symptoms in a child with no neurologic deficit are irritability, headache, and vomiting. In infants younger than 1 year of age, the most common symptoms are irritability, pallor with anemia, and cephalhematoma. DIF: Cognitive Level: Applying REF: MCS: 1446 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 4. The nurse is caring for a child with a subdural hematoma. The nurse should assess for twha signs that canciantdeibrainstem co mpression? (Select all that apply.) a. Coma b. Lethargy c. Hemiplegia d. Hemiparesis e. Unequal pupils ANS: C, D, E Hemiparesis, hemiplegia, and anisocoria (unequal pupils) are signs of brainstem compression and require emergency treatment targeted at decreasing increased intracranial pressure. Coma and lethargy are seen with a subdural hematoma but do not indicate a brainstem compression. DIF: Cognitive Level: Analyzing REF: MCS: 1447 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. The nurse is preparing to admit a tneeowna ith bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Jaundice b. Cyanosis c. Poor tone d. Nuchal rigidity e. Poor sucking ability ANS: A, B, C, E Clinical manifestations of bacterial meningitis in a neonate include jaundice, cyanosis, poor tone, and poor sucking ability. The neck is usually supple in neonates with meningitis, and there is no nuchal rigidity. DIF: Cognitive Level: Applying REF: MCS: 1456 TOP: Nursing Process: Assessment :MCSC lient :NPeeds hysiological Integrity 6. The enuisrspr eparing toiat damn a dolescent with tbearcial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Fever b. Chills c. Headache d. Poor tone e. Drowsiness ANS: A, B, C, E Clinical manifestations of bacterial meningitis in an adolescent include, fever, chills, headache, and drowsiness. Hyperactivity is present, not poor tone. DIF: Cognitive Level: Applying REF: MCS: 1456 TOP: Nursing Process: Assessment :MCSC ielnt Needs: Physiological Integrity 7. The nurse is caring for a child with meningitis. What acute complications of meningitis should the nurse continuously assess the child for? (Select all that apply.) a. Seizures b. Cerebral palsy c. Cerebral edema d. Hydrocephalus e. Cognitive impairments ANS: A, C, E Acute complications of meningitis include syndrome of inappropriate antidiuretic hormone (SIADH), subdural effusions, seizures, cerebral edema and herniation, and hydrocephalus. Long- termpcloications inc lude rce ebral iptaivlsey, cogn deficit hyperactivity disorder, and seizures. DIF: Cognitive Level: Applying REF: MCS: 1440 impairmarennintsg, dlei sorder, attention TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. What cerebrospinal fluid (CSF) analysis should the nurse expect with viral meningitis? (Select all that apply.) a. Color is turbid. b. Protein count is normal. c. Glucose is decreased. d. Gram stain findings are negative. e. White blood cell (WBC) count is slightly elevated. ANS: B, D, E The CSF analysis in viral meningitis shows a normal or slightly elevated protein count, negative Gram stain, and a slightly elevated WBC. The color is clear or slightly cloudy, and the glucose level is normal. DIF: Cognitive Level: Applying REF: MCS: 1460 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. The nurse is preparing totaadnmaidol escent with encephalitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Malaise b. Apathy c. Lethargy d. Hypoactivity e. Hypothermia ANS: A, B, D The clinical manifestations of encephalitis include malaise, apathy, and lethargy. There is hyperactivity, not hypoactivity, and hyperthermia, not hypothermia. DIF: Cognitive Level: Applying REF: MCS: 1461 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 10. The nurse is preparing to admit a 7-year-old child with complex partial seizures. What clinical features of complex partial seizures should the nurse recognize? (Select all that apply.) a. They last less than 10 seconds. b. There is usually no aura. c. Mental disorientation is common. d. There is frequently a postictal state. e. There is usually an impaired consciousness. ANS: C, D, E Clinical features of complex ptiar l lsuedizeures inc the following: it is common tovhea nmteal disorientation, there is frequently a postictal state, and there is usually an impaired consciousness. These seizures last longer than 10 seconds (usually longer than 60 seconds), and there is usually an aura. DIF: Cognitive Level: Analyzing REF: MCS: 1466 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. What effects of an altered pituitary secretion in a child with meningitis indicates syndrome of inappropriate antidiuretic hormone (SIADH)?th(aStelect all apply.) a. Hypotension b. Serum sodium is decreased c. Urinary output is decreased d. Evidence of overhydration e. Urine specific gravity is increased ANS: B, C, D, E The serum sodium is decreased, urinary output is decreased, evidence of overhydration is present, and urine specific gravity is increased in SIADH. Hypertension, not hypotension, occurs. DIF: Cognitive Level: Analyzing REF: MCS: 1440 TOP: Nursing Process: Assessment MSC: iCelnt Needs: Physiological Integrity 12. The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.) a. Fever b. Flushing c. Bradycardia d. Systemic hypertension e. Respiratory depression ANS: C, D, E Cushing triad (systemic hypertension, bradycardia, and respiratory depression) is a late sign of impending brainstem herniation. Fever or flushing does not occur with Cushing triad. DIF: Cognitive Level: Applying REF: MCS: 1446 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. The nurse is preparing to admit a 10-year-old child with absence seizures.tWclhinaical features of absence seizures should the nurse recognize? (Select all that apply.) a. There is no aura. b. There is a postictal state. c. They usually last longer than 30 seconds. d. There is a brief loss of consciousness. e. There is an occasional clonic movement. ANS: A, D, E Clinical features of absence seizures include no auras, a brief loss of consciousness, and an occasional clonic movement. rTehies no postictal state, and the seizures rarely last longer than 30 seconds. DIF: Cognitive Level: Understanding REF: MCS: 1466 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 14. The nurse is teaching the parents of a child with a seizure disorder about the triggers that can cause a seizure. tWshoau ld tnhuerse include in t theaeching session? (Select all that apply.) a. Cold b. Sugared drinks c. Emotional stress d. Flickering lights e. Hyperventilation ANS: C, D, E The most common factors that may itgr ger seizures in ch ildren include emotional stress, sleep deprivation, fatigue, fever, and physical exercise. Other precipitating factors include sleep, flickering lights, menstrual cycle, alcohol, heat, hyperventilation, and fasting. Cold and sugared drinks are not triggers for seizures. DIF: Cognitive Level: Applying REF: MCS: 1480 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity COMPLETION 1. The health care provider has prescribed fosphenytoin (Cerebyx) 4 mg/kg/day divided every 12 hours for a child with a seizure disorder. The child weighs 55 lb. The nurse is preparing to administer the 1200 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 50 The correct calculation is: 55 lb/2.2 kg = 25 kg divided every 12 hours Dose of Cerebyx is 4 mg/kg 4 25 = 100 mg/2 = 50 mg DIF: Cognitive Level: Applying REF: MCS: 1438 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The health care provider has prescribed gabapentin (Neurontin) 30 mg/kg/day divided q 8 hours for a child with a seizure disorder. The child weighs 110 lb. The nurse is preparing to administer the 1200 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 500 The correct calculation is: 110 lb/2.2 kg = 50 kg Dose of Neurontin is 30 mg/kg/day divided every 8 hours 30 mg 50 = 1500 mg/day 1500 mg/3 = 500 mg for one dose DIF: Cognitive Level: Applying REF: MCS: 1469 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The health care provider has prescribed valproic acid (Depakene) 30 mg/kg/day divided bid for a child with a seizure disorder. The child weighs 77 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 525 The correct calculation is: 77 lb/2.2 kg = 35 kg Dose of Depakene is 30 mg/kg/day divided bid 30 mg 35 = 1050 mg 1050 mg/2 = 525 mg for one dose Chapter 31.The Child with Endocrine Dysfunction MULTIPLE CHOICE 1. Homeostasis in the body is maintained by what is collectively known as the neuroendocrine system. What is the name of the nervous system that is involved? a. Central b. Skeletal c. Peripheral d. Autonomic ANS: D The autonomic nervous system p(coosmed of the sympathetic and parasympathetic systems) controulnstainryvofl unctions. mInbcinationo with the endocrine sytem, it maintains homeostasis. The central, skeletal, and peripheral subdivisions of the nervous system are not part of the neuroendocrine system. DIF: Cognitive Level: Understanding REF: MCS: 1494 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing considerations should be based on which knowledge? a. Therapy is most successful if it is started during adolescence. b. Replacement therapy requires daily subcutaneous injections. c. Hormonal supplementation will be required throughout childs lifetime. d. Treatment is considered successful if children attain full stature by adolescence. ANS: B Additional support is required for children who require hormone replacement therapy, such as preparation for daily subcutaneous injections and education for self-management during the school-age years. Young children, lodbreesne, chi and those who are severely GH deficient have the best response to therapy. Replacement therapy is not needed after attaining final height. The children are no longer GH deficient. When therapy is successful, children can attain their actual or near-final adult height at a slower rate than their peers. DIF: Cognitive Level: Analyzing REF: MCS: 1499 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 3. A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time for the GH to be administered? a. At bedtime b. After meals c. Before meals d. After arising in morning ANS: A Injections are best given at bedtime to more closely approximate the physiologic release of GH. After meals, before meals, and after arising in the morning do not parallel the opghiycsiroel of the hormone. DIF: Cognitive Level: Applying REF: MCS: 1499 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity aslee 4. What is a condition that can result if hypersecretion of growth hormone (GH) occurs after epiphyseal closure? a. Cretinism b. Dwarfism c. Gigantism d. Acromegaly ANS: D Excess GH after closure of the epiphyseal aptle s results in acromegaly. Cretinism is associated with hypothyroidism. Dwarfism is the condition of being abnormally small. Gigantism occurs when there is hypersecretion of GH before the closure of the epiphyseal plates. DIF: Cognitive Level: Understanding REF: MCS: 1501 TOP: Nursing Process: Assessment :MCSC ielnt Needs: Physiological Integrity 5. Peripheral precocious puberty (PPP) differs from central precocious puberty (CPP) in which manner? a. PPP results from a central nervous system (CNS) insult. b. PPP occurs more frequently in girls. c. PPP may be viewed as a variation in sexual development. d. PPP results from hormonal stimulation of the hypothalamic gonadotropin- releasing hormone (Gn-RH). ANS: C PPP may be viewed as a variation in sexual development. PPP results from hormone stimulation other than the hypothalamic Gn-RH. Isolated manifestations of secondary sexual development occur. PPP can be missed if tsheechanges are viewed as variations in pubertal onset.PCrP esults from CNS insult, uorcsc more f requently in girls, and results from hormonal stimulation of the hypothalamic Gn-RH. DIF: Cognitive Level: Understanding REF: MCS: 1502 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. A cldhiw ill start treatment for central precocious puberty. What synthetic hormone will be injected? a. Thyrotropin b. Gonadotropins c. Somatotropic hormone d. Luteinizing hormonereleasing hormone ANS: D Precocious puberty of central origin is treated with monthly subcutaneous injections of luteinizing hormonereleasing hormone, which regulates pituitary secretions. Thyrotropin, gonadotropins, and somatotropic hormone are not the appropriate therapies for precocious puberty. DIF: Cognitive Level: Understanding REF: MCS: 1502 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. The nurse is planning care for a child recently diagnosed with diabetes insipidus (DI). What intervention should be included? a. Encourage the child to wear medical identification. b. Discuss with the child and family ways to limit fluid intake. c. Teach the child and family how to do required urine testing. d. Reassure the child and family that this is usually not a chronic or life-threatening illness. ANS: A DI is a potentially life-threatening disorder if the voluntary demand for fluid is suppressed or the child does not have access to fluids. Medical alert identification should be worn. Fluid intake is not restricted in children with DI. The child is unable to concentrate urine and can rapidly become dehydrated. Fluid intake may be limited during diagnosis, when the lack of intake will result in decreased urinary output and dehydration. Urine testing is not required in DI. Changes in body weight provide information about approximate fluid balance. This is a lifelong disorder that requires supplemental vasopressin throughout life. DIF: Cognitive Level: Applying REF: MCS: 1502 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 8. Intranasal administration of desmopressin acetate (DDAVP) is used to treat which condition? a. Hypopituitarism b. Diabetes insipidus (DI) c. Syndrome of inappropriate antidiuretic hormone (SIADH) d. Acute adrenocortical insufficiency ANS: B DDAVP is the treatment of choice for DI. mIt iinsiastdered i ntranasally tehxriobuleghtuabefl. The childs response pattern is variable, with effectiveness lasting from 6 to 24 hours. DIF: Cognitive Level: Understanding REF: MCS: 1503 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 9. What nursing care should be included for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Maintain the child NPO (nothing by mouth). b. Turn the child frequently. c. Restrict fluids. d. Encourage fluids. ANS: C Increased secretion of ADH causes the kidney toorrebabws ater, which increases fluid volume and decreases serum osmolarity with a progressive reduction in sodium concentration. The immediate management of the child is to restrict fluids but not food. Frequently turning the child is not necessary unless the child is unresponsive. Encouraging fluids will worsen the childs condition. DIF: Cognitive Level: Analyzing REF: MCS: 1504 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 10. What is a common clinical manifestation of juvenile hypothyroidism? a. Insomnia b. Diarrhea c. Dry skin d. Rapid growth ANS: C Dry skin, mental decline, and myxedematous skin changes are associated with juvenile hypothyroidism. Children with hypothyroidism often have sleepiness, constipation, and decelerated growth. DIF: Cognitive Level: Understanding REF: MCS: 1505 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. A goiter is an enlargement or hypertrophy of which gland? a. Thyroid b. Adrenal c. Anterior pituitary d. Posterior pituitary ANS: A A goiter is an enlargement or hypertrophy of the thyroid gland. Goiter is not associated with the adrenal, anterior pituitary, or posterior pituitary secretory organs. DIF: Cognitive Level: Understanding REF: MCS: 1505 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 12. Exophthalmos (protruding eyeballs) may occur in children with which condition? a. Hypothyroidism b. Hyperthyroidism c. Hypoparathyroidism d. Hyperparathyroidism ANS: B Exophthalmos is associated with hyperthyroidism. Hypothyroidism, hypoparathyroidism, and hyperparathyroidism are not associated with exophthalmos. DIF: Cognitive Level: Understanding REF: MCS: 1507 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. A cldhii s receiving propylthiouracil for the treatment of hyperthyroidism (Graves disease). The parents and child should be taught to recognize and report which sign or symptom immediately? a. Fatigue b. Weight loss c. Fever, sore throat d. Upper respiratory tract infection ANS: C Children being treated with propylthiouracil must be carefully monitored for the side effects of the drug. Parents must be alerted that sore throat and fever accompany the grave complication of leukopenia. These symptoms should be immediately reported. Fatigue and weight loss are manifestations of hyperthyroidism. Their presence may indicate that the drug is not effective but does not require immediate evaluation. Upper respiratory tract infections are most likely viral in origin and not a sign of leukopenia. DIF: Cognitive Level: Applying REF: MCS: 1507 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 14. The school nurse practitioner is consulted by a fifth-grade teacher about a student who has become increasingly inattentive and hyperactive in the classroom. The nurse notes that the childs weight has changed from the 50th percentile to the 30th percentile. The nurse is concerned about possible hyperthyroidism. What additional sign or symptom should the nurse anticipate? a. Skin that is cool and dry b. Blurred vision and loss of acuity c. Running and being active during recess d. Decreased appetite and food intake ANS: B Visual disturbances such as loss of visual acuity and blurred vision are associated with hyperthyroidism. They may occur before the actual onset of other symptoms. The childs skin is usually warm, flushed, and moist. Although the signs of hyperthyroidism include excessive motion, irritability, hyperactivity, short attention span, and emotional lability, these children are easily fatigued and require frequent rest periods. Children with hyperthyroidism have increased food intake. Even with voracious appetites, weight loss occurs. DIF: Cognitive Level: Applying REF: MCS: 1507 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 15. A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which signs or symptoms of vitamin D toxicity? a. Headache and seizures b. Weakness and lassitude c. Anorexia and insomnia d. Physical restlessness, voracious appetite without weight gain ANS: B Vitamin D toxicity can rbieouassceonsequence of therapy. Parents are advised to watch for weakness, fatigue, lassitude, chheea,dna ausea, vomiting, and diarrhea. Renal impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign of vitamin D toxicity, but seizures are not. Anorexia and insomnia are not characteristic of vitamin D toxicity. Physical restlessness and a voracious appetite with weight sloasre manifestations of hyperthyroidism. DIF: Cognitive Level: Applying REF: MCS: 1509 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 16. Glucocorticoids, mineralocorticoids, and sex steroids are secreted by which gland? a. Thyroid gland b. Adrenal cortex c. Anterior pituitary d. Parathyroid glands ANS: B The glucocorticoids, mineralocorticoids, and sex steroids are secreted by the adrenal cortex. The thyroid gland produces thyroid hormone and thyrocalcitonin. The anterior pituitary produces hormones such as growth hormone, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The parathyroid glands produce parathyroid hormone. DIF: Cognitive Level: Understanding REF: MCS: 1510 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 17. Congenital adrenal hyperplasia (CAH) is suspected in a newborn because of ambiguous genitalia. The parents are appropriately upset and concerned about their childs gender. In teaching the parents about CAH, what should the nurse explain? a. Reconstructive surgery as a female is preferred. b. Sexual assignment should wait until genetic sex is determined. c. Prenatal masculinization will strongly influence the childs development. d. The child should be raised as a boy because of the presence of a penis and scrotum. ANS: B It is preferable to raise the lcdhiaccording totgicense ex. With hormone replacement and surgical intervention ifdn,eede genetically female children achieve satisfactory results in reversing virilism and achieving normal puberty and ability to conceive. Reconstructive surgery as a female is only preferred for ainnfts who are genetically female. Infants who are genetically male should be given hormonal supplementation. Sex assignment and rearing depend on psychosocial influences, not on genetic sex hormone influences during fetal life. It is not advised to raise the child as a boy because of the presence of a penis and scrotum unless the child is genetically male. If a genetic female, the child will be sterile and may never be able to function satisfactorily in a heterosexual relationship. DIF: Cognitive Level: Applying REF: MCS: 1517 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 18. What form of diabetes is characterized by destruction of pancreatic beta cells, resulting in insulin deficiency? a. Type 1 diabetes b. Type 2 diabetes c. Gestational diabetes d. Maturity-onset diabetes of the young (MODY) ANS: A Type 1 diabetes is characterized by the destruction of the pancreatic beta cells, which leads to absolute insulin deficiency. Type 2 diabetes results usually from insulin resistance. The pancreatic beta cells are not rdoeysted i n gestational diabetes. MODY is an autosomal dominant monogenetic defect in beta cell function that is characterized by impaired insulin secretion with minimum or no defects in insulin action. DIF: Cognitive Level: Understanding REF: MCS: 1519 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 19. What statement is characteristic of type 1 diabetes mellitus? a. Onset is usually gradual. b. Ketoacidosis is infrequent. c. Peak age incidence is 10 to 15 years. d. Oral agents are available for treatment. ANS: C Type 1 diabetes mellitus typically usually has its onset before the age of 20 years, with a peak incidence between ages 10 and 15 years. Type 1 has an abrupt onset, in contrast to type 2, which has a more gradual appearance. oKaectidosis occurs when i nsulin is unavailable and the body uses sources other than glucose for cellular metabolism. Ketoacidosis is more common in type 1 diabetes than in type 2. At this time, oral agents are available only for type 2 diabetes. DIF: Cognitive Level: Analyzing REF: MCS: 1520 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 20. What clinical manifestation is considered a cardinal sign of diabetes mellitus? a. Nausea b. Seizures c. Impaired vision d. Frequent urination ANS: D Hallmarks of diabetes mellitus are glycosuria, ypuolria, and polydipsia. Nausea and seizures are not clinical manifestations of diabetes mellitus. Impaireiodnvis the disease. DIF: Cognitive Level: Understanding REF: MCS: 1523 is a long-term complication of TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 21. What blood glucose measurement is most likely associated with diabetic ketoacidosis? a. 185 mg/dl b. 220 mg/dl c. 280 mg/dl d. 330 mg/dl ANS: D Diabetic ketoacidosis is a state of relative insulin insufficiency and may liundce the presence of hyperglycemia, a blood glucose level greater than or equal to 330 mg/dl; 185, 220, and 280 mg/dl are values that are too low for the definition of ketoacidosis. DIF: Cognitive Level: Understanding REF: MCS: 1530 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 22. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. What effect does exercise have on a type 1 diabetic? a. Exercise increases blood glucose. b. Extra insulin is required during exercise. c. Additional snacks are needed before exercise. d. Excessive physical activity should be restricted. ANS: C Exercise lowers blood glucose levels, decreasing the need for insulin. Extra snacks are provided to maintain the blood glucose levels. Exercise is encouraged and not restricted unless indicated by other health conditions. DIF: Cognitive Level: Applying REF: MCS: 1527 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 23. A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid- releasing sugar should be followed by which dietary intervention? a. Sports drink and fruit b. Glucose tabs and protein c. Glass of water and crackers d. Milk and peanut butter on bread ANS: D Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a complex carbohydrate and protein. Milk supplies lactose and a more prolonged action from the protein. The bread is a complex carbohydrate, which with the peanut butter provides a sustained action. The sports drink contains primarily simple carbohydrates. The fruit contains additional carbohydrates. A protein source is needed for sustained action. The glucose tabs are simple carbohydrates. mCoplex carbohydrates are needed w ith the protein. Crackers are a complex carbohydrate, but protein is needed to stabilize the blood sugar. DIF: Cognitive Level: Applying REF: MCS: 1528 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 24. A 20-kg (44-lb) child in ketoacidosis is admitted to the apterdici intensive rca e unit. tWha order should the enunrs ot implement until clarified with the physician? a. Weigh on admission and daily. b. Replace fluid volume deficit over 48 hours. c. Begin intravenous line with D5 0.45% normal saline with 20 mEq of potassium chloride. d. Give intravenous regular insulin 2 units/kg/hr after initial rehydration bolus. ANS: C The initial hydrating solution is 0.9% normal saline. Potassium is not given until the child is voiding 25 ml/hr, demonstrating adequate renal function. After initial rehydration and insulin administration, then potassium is given. Dextrose is not given until blood glucose levels are between 250 and 300 mg/dl. An accurate, current weight is essential for determination of the amount of fluid loss and as a basis for medication dosage. Replacing fluid volume deficit over 48 hours is the current recommendation inbdeitaic ketoacidosis in c hildren. Cerebral edema is a risk of more rapid administration. Intravenous regular insulin 2 /ukngi/ths r afte r initial rehydration bolus is the recommended insulin administration for a child of this weight. Only regular insulin can be given intravenously, and it is given after initial fluid volume expansion. DIF: Cognitive Level: Applying REF: MCS: 1530 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. What clinical manifestation occurs with hypoglycemia? a. Lethargy b. Confusion c. Nausea and vomiting d. Weakness and dizziness ANS: D Some of the clinical manifestations of hypoglycemia include weakness; dizziness; difficulty concentrating, speaking, focusing, and coordinating; sweating; and pallor. Lethargy, confusion, and nausea and vomiting are manifestations of hyperglycemia. DIF: Cognitive Level: Understanding REF: MCS: 1537 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 26. A 12-year-old girl is newly diagnosed with diabetes when she develops ketoacidosis. How should the nurse structure a successful teidounca program? a. Essential information is presented initially. b. Teaching should take place in the childs semiprivate room. c. Education is focused toward the parents because the child is too young. d. All information needed for self-management of diabetes is taught at once. ANS: A Diagnosis of type 1 diabetes can be traumatic for the child andmfaily. Most families are not psychologically ready for the complex teaching that is needed for self-management. Most structured diabetes education programs begin with essential or survival information followed by the complex background material when the family is better able to learn. Teaching can tpalkacee either as an outpatient or as an inpatient. The actual teaching area should be free from distractions that would interfere with learning. A semiprivate room would have many individuals entering and leaving the room, causing distraction. A 12-year-old child who is cognitively age appropriate needs to be included in the educational process. Most children older than the age of 8 years can be involved in blood glucose monitoring and insulin administration. Teaching all information needed for self-management of diabetes at once would be too overwhelming for a family in crisis. DIF: Cognitive Level: Applying REF: MCS: 1524 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 27. The nurse is discussing with a child and family the various sites used for insulin injections. What site usually has the fastest rate of absorption? a. Arm b. Leg c. Buttock d. Abdomen ANS: D The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but a short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration. DIF: Cognitive Level: Applying REF: MCS: 1525 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 28. The nurse is teaching an adolescent about giving insulin injections. The adolescent asks if the disposable needles and syringes can be used more than once. The nurses response should be based on which knowledge? a. It is unsafe. b. It is acceptable for up to 24 hours. c. It is acceptable for families with very limited resources. d. It is suitable for up to 3 days if stored in the refrigerator. ANS: D Bacterial counts are unaffected if insulin syringes are handled iniacnmaasnenpet r and stored in the refrigerator between use. The syringes can be used up to 3 days and result in a considerable cost savings. Bacterial counts remain low for up to 72 hours with proper technique. The familys resources are not an issue; if a practice is unsafe, the family should not be encouraged to endanger the child by reusing equipment. DIF: Cognitive Level: Applying REF: MCS: 1526 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 29. A preadolescent has maintained good glycemic control of his type 1 diabetes through the school year. During summer vacation, he has had repeated episodes of hypoglycemia. What additional teaching is needed? a. Carbohydrates in the diet need to be replaced with protein. b. Additional snacks are needed to compensate for increased activity. c. The child needs to decrease his activity level to minimize episodes of hypoglycemia. d. Insulin dosage should be increased to compensate for a change in activity level. ANS: B Most children have a different schedule during summer vacation. The increased activity and exercise reduce insulin resistance and increase glucose utilization. Additional snacks should be eaten before physical activity to increase carbohydrates and protein and compensate for increased activity. Physical activity should always be encouraged if tchheild i s capable. The benefits include improved glucose utilization and decreased insulin requirements. In consultation with the practitioner, insulin dosage may need to be decreased because of improved glucose utilization. DIF: Cognitive Level: Applying REF: MCS: 1526 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 30. To help an adolescent deal with diabetes, the nurse needs to consider which characteristic of adolescence? a. Desire to be unique b. Preoccupation with the future c. Need to be perfect and similar to peers d. Awareness of peers that diabetes is a severe disease ANS: C Adolescence is a time when the individual has a need to be perfect and similar to peers. Having diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they desire to fit in with the peer group. An adolescent is usually not future oriented. Awareness of peers that diabetes is a severe disease would further alienate the adolescent with diabetes. The peer group would focus on the differences. DIF: Cognitive Level: Analyzing REF: MCS: 1538 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 31. An adolescent diabetic is admitted to the emergency department for treatment of hyperglycemia and pneumonia. What are characteristics of diabetic hyperglycemia? a. Cold, clammy skin and lethargy b. Hunger and hypertension c. Thirst, being flushed, and fruity breath d. Disorientation and pallor ANS: C The signs of hyperglycemia are thirst, being flushed, and fruity breath. The skin is not cold or clammy, and there is not hunger and hypertension. Disorientation and pallor are signs of hypoglycemia. DIF: Cognitive Level: Understanding REF: MCS: 1528 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 32. A school-age child with diabetes gets 30 units of NPH insulin at 0800. According to when this insulin peaks, the child should be at greatest risk for a hypoglycemic episode between when? a. Lunch and dinner b. Breakfast and lunch c. 0830 to his midmorning snack d. Bedtime and breakfast the next morning ANS: A Intermacetidnigat(eN- PH and Lente) insulins reach the blood 2 to 6 hours after injection. The insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. DIF: Cognitive Level: Analyzing REF: MCS: 1525 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 33. The nurse is teaching tphaerent ofsachporeol child how to administer the childs insulin injection. The child will be receiving 2 units of regular insulin and 12 units of NPH insulin every morning. What should the parent be taught? a. Draw the insulin in separate syringes. b. Draw the regular insulin first and then the NPH into the same syringe. c. Draw the NPH insulin first and then the regular into the same syringe. d. Check blood sugar first, and if below 120, hold the regular insulin and give the NPH. ANS: B To obtain maximum benefit from mixing insulins, the oremcmended pr actice is to (1) inject the measured amount of air (equivalent to the dosage) into the long-acting insulin; (2) inject the measured amount of air into the rapid-acting (clear) insulin and, without removing the needle; (3) withdraw the acrleinsulin; and (4) insert the needle (already containing the clear insulin) into the long-acting (cloudy) insulin and then withdraw the desired amount. The blood sugar may be checked before giving the insulin, but the prescribed dose should not be withheld if the blood sugar is 120. DIF: Cognitive Level: Applying REF: MCS: 1535 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 34. What statement easpptoli t he current ufoscof the dietary management of children with diabetes? a. Measurement of all servings of food is vital for control. b. Daily calculate specific amounts of carbohydrates, fats, and proteins. c. The number of calories for carbohydrates remains constant on a daily basis; protein and fat calories are liberal. d. The intake ensures day-to-day consistency in total calories, protein, carbohydrates, and moderate fat while allowing for a wide variety of foods. ANS: D Essentially the nutritional needs of children with diabetes are no different from those of healthy children. Children with diabetes need no special foods or supplements. They need sufficient calories to balance daily expenditure for energy and to satisfy the requirement for growth and development. DIF: Cognitive Level: Analyzing REF: MCS: 1526 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 35. During the summer many children are more physically active. What changes in the management of the child with diabetes should be expected as a result of more exercise? a. food intake b. food intake c. risk of hyperglycemia d. risk of insulin reaction ANS: A Exercise is encouraged and never restricted unless indicated by other health conditions. Exercise lowers blood glucose levels, depending on the intensity and duration of the activity. Consequently, exercise should be included as part of diabetes management, and the type and amount of exercise should be planned around the childs interests and capabilities. However, in most instances, childrens activities are unplanned, and the resulting decrease in blood glucose can be compensated for by providing extra snacks before (and, if the exercise is prolonged, during) the activity. In addition toealifneg of well-being, regular exercise aids in utilization of food and often results in a reduction of insulin requirements. DIF: Cognitive Level: Analyzing REF: MCS: 1527 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 36. Prolonged steroid therapy has caused a child to have Cushing syndrome. To lessen the cushingoid effects, the steroid should be administered at which time? a. In the PM b. After lunch c. QD in the AM d. QOD in the AM ANS: D When cushingoid features are caused by steroid therapy, the effects may be lessened with administration of the drug early in the morning and on an alternate-day basis. Giving the drug early in the day maintains the normal diurnal pattern of cortisol secretion. If given during the evening, it is more likely to produce symptoms because endogenous cortisol levels are normally low and the additional supply exerts more pronounced effects. An alternate-day schedule allows the anterior pituitary an opportunity to maintain more normal hypothalamicpituitaryadrenal control mechanisms. DIF: Cognitive Level: Applying REF: MCS: 1515 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 37. The thyroid-stimulating hormone (TSH) increases secretion in response to which hormone? a. Low levels of circulating thyroid hormone b. High levels of circulating thyroid hormone c. Low levels of circulating adrenocorticotropic hormone d. High levels of circulating adrenocorticotropic hormone ANS: A As blood concentrations of the target hormones reach normal levels, a negative message is sent to the anterior pituitary to inhibit release of the tropic hormone. For example, TSH responds to low levels of circulating TH. As blood levels of TH reach normal concentrations, a negative feedback message is sent to the anterior pituitary, resulting in diminished release of TSH. Adrenocorticotropic stimulates the adrenals to secrete glucocorticoids. DIF: Cognitive Level: Understanding REF: MCS: 1494 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 38. The nurse is caring for an adolescent with anorexia nervosa. What pituitary dysfunction should the nurse assess for in the adolescent? a. Hypopituitarism b. Pituitary hyperfunction c. Hyperplasia of the pituitary cells d. Overproduction of the anterior pituitary hormones ANS: A Anorexia nervosa can cause hypopituitarism. It does not cause the hyperfunction of the pituitary, hyperplasia of the pituitary cells, or overproduction of the anterior pituitary hormones. DIF: Cognitive Level: Understanding REF: MCS: 1496 TOP: NursoicnegssP:rAssessment :MCSlCient Needs: Physiological Integrity 39. The clinic nurse is assessing a child with hypopituitarism. Hypopituitarism can lead to which disorder? a. Gigantism b. Hyperthyroidism c. Cushing syndrome d. Growth hormone deficiency ANS: D Hypopituitarism can lead to a growth hormone deficiency. An overproduction of the anterior pituitary hormones can result in gigantism (caused by excess growth hormone production during childhood), hyperthyroidism, or hypercortisolism (Cushing syndrome). DIF: Cognitive Level: Understanding REF: MCS: 1500 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 40. The enuisrsa ssisting with tahghror mone ustliamtion test for a child with short stature. What should the nurse monitor closely on this child during the test? a. Hypotension b. Tachycardia c. Hypoglycemia d. Nausea and vomiting ANS: A Patients receiving clonidine t(aCpares) for a g rowth hormone stimulation test require close blood pressure monitoring for hypotension. Tachycardia, hypoglycemia, and nausea and vomiting do not occur with Catapres administered for a growth hormone stimulation test. DIF: Cognitive Level: Applying REF: MCS: 1500 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment 41. The nurse is preparing tonaidstmeri a prescribed dos e of desmopressin acetate (DDAVP) intramuscularly (IM) to a child with diabetes insipidus. What action should the nurse take before drawing the medication into a syringe? a. Mix the medication with sterile water. b. Mix the medication with sterile normal saline. c. Have another nurse double-check the medication dose. d. Hold the medication under warm water for 10 to 15 minutes and then shake vigorously. ANS: D To be effective, vasopressin must be thoroughly mixed in the oil by being held under warm running water for 10 to 15 minutes and shaken vigorously before being drawn into the syringe. If this is not done, the oil may be injected minus the antidiuretic hormone. Small brown particles, which indicate drug dispersion, must be seen in the suspension. DIF: Cognitive Level: Applying REF: MCS: 1503 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 42. The nurse is taking care of a child who had a thyroidectomy. The nurse recognizes what as a positive Chvostek sign? a. Paresthesia occurring in feet and toes b. Frequent sharp flexion of wrist and ankle joints c. Carpal spasm elicited by pressure applied to the nerves of the upper arm d. Facial muscle spasm elicited by tapping the facial nerve in the region of the parotid gland ANS: D A positive Chvostek sign is a facial muscle spasm that is elicited by tapping the facial nerve in the region of the parotid gland. Paresthesia occurring in the feet and toes and frequent sharp flexion of the wrist and ankle joints can be signs of hypoparathyroidism but are not part of a positive Chvostek sign. Carpal spasm elicited by pressure applied to nerves of the upper arm is called a positive Trousseau sign. DIF: Cognitive Level: Analyzing REF: MCS: 1508 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 43. A child is having tests done to determine parathyroid function. The clinic nurse knows that the parathyroid hormone (PTH) regulates the homeostasis of what in the serum? a. Sodium b. Calcium c. Potassium d. Magnesium ANS: B The parathyroid glands secrete PTH. Along with vitamin D and calcitonin, PTH regulates the homeostasis of serum calcium concentrations. DIF: Cognitive Level: Understanding REF: MCS: 1508 TOP: Nursing Process: Assessment :MCSC lient Needs: Health Promotion and Maintenance 44. The nurse is caring for a child after a parathyroidectomy. What medication should the nurse have available ifcheympioacoacl curs? a. Insulin b. Calcium gluconate c. Propylthiouracil (PTU) d. Cortisone (hydrocortisone) ANS: B Because hypocalcemia is a potential complication after a parathyroidectomy, observing for signs of tetany, instituting seizure precautions, and having calcium gluconate available for emergency use are part of the nursing care. DIF: Cognitive Level: Applying REF: MCS: 1510 TOP: NursoicnegssP:rAssessment MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is preparing a community outreach program for adolescents about the characteristic differences between type 1 and type 2 diabetes mellitus (DM). What concepts should the nurse include? (Select all that apply.) a. Type 1 DM has an abrupt onset. b. Type 1 DM is often controlled with oral glucose agents. c. Type 1 DM occurs primarily in whites. d. Type 2 DM always requires insulin therapy. e. Type 2 DM frequently has a familial history. f. Type 2 DM occurs in people who are overweight. ANS: A, C, E, F Characteristics of type 1 DM include having an abrupt onset, primarily occurring in whites, and not being controlled with oral glucose agents (insulin is required for therapy). Type 2 DM frequently has a familial history, occurs in people who are overweight, and does not always require insulin therapy (it is used in 20% to 30% of patients). DIF: Cognitive Level: Analyzing REF: MCS: 1520 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 2. The nurse is preparing to admit a 9-year-old child with dsyronme o f inappropriate antidiuretic hormone (SIADH). What interventions should the nurse include in the childs care plan? (Select all that apply.) a. Provide a low-sodium, low-fat diet. b. Initiate seizure precautions. c. Weigh daily at the same time each day. d. Encourage intake of 1 l of fluid per day. e. Measure intake and output hourly. ANS: B, C, E Nursing care of the child with SIADH includes placing ithlde ocnh seizure precautions, obtaining gahdtaailtythweei same time each day, and accurately measuring the childs intake and output. The nurse does not need to provide a low-sodium, low-fat diet because there are no diet restrictions. The child would be on fluid precautions to avoid fluid overload, so 1 l of fluid would not be encouraged. DIF: Cognitive Level: Applying REF: MCS: 1505 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The nurse is planning to admit a 14-year-old adolescent with Cushing syndrome. What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Truncal obesity b. Decreased pubic hair c. Petechial hemorrhage d. Hyperpigmentation of elbows e. Facial plethora f. Headache and weakness ANS: A, C, E Clinical manifestations of Cushing syndrome include truncal obesity, petechial hemorrhage, and facial plethora. Decreased pubic and axillary hair; hyperpigmentation of elbows, knees, and wrists; and headache and weakness are clinical manifestations of adrenocortical insufficiency. DIF: Cognitive Level: Applying REF: MCS: 1514 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. The nurse is teaching the family of a child with type 1 diabetes about insulin. What should the nurse include in the teaching session? (Select all that apply.) a. Unopened vials are good for 60 days. b. Diabetic supplies should not be left in a hot environment. c. Insulin can be placed in the freezer if not used every day. d. After it has been opened, insulin is good for up to 28 to 30 days. e. Insulin bottles that have been opened should be stored at room temperature or refrigerated. ANS: B, D, E Insulin bottles that have been opened (i.e., the stopper has been punctured) should be stored at room temperature or refrigerated for up to 28 to 30 days. After 1 month, these vials should be discarded. Unopened vials should be refrigerated and are good until the expiration date on the label. Diabetic supplies should not be left in a hot environment. Insulin need not be refrigerated but should be maintained at a temperature between 15 and 29.5 C (59 and 85 F). Freezing renders insulin inactive. DIF: Cognitive Level: Applying REF: MCS: 1534 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is caring for a child with an anterior pituitary tumor. What hormones are secreted by the anterior pituitary? (Select all that apply.) a. Oxytocin b. Luteinizing hormone c. Antidiuretic hormone d. Thyroid-stimulating hormone e. Adrenocorticotrophic hormone ANS: B, D, E The anterior pituitary is responsible for secreting the following hormones: growth hormone, thyroid-stimulating hormone, adrenocorticotrophic hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin. The posterior pituitary secretes antidiuretic hormone and oxytocin. DIF: Cognitive Level: Analyzing REF: MCS: 1495 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. The nurse is preparing to assist with a growth hormone provocative test for a child with short stature. The nurse recognizes that which pharmacologics should be used to provoke the release of growth hormone (GH)? (Select all that apply.) a. Larodopa (levodopa) b. Clonidine (Catapres) c. Propranolol (Inderal) d. Cortisone (hydrocortisone) e. Biosynthetic growth hormone ANS: A, B, C GH stimulation, or provocative testing, involves the use of pharmacologics to provoke the release of GH er idthireectly o r indirectly. Provocative testing involves the use of neuromodulators such as levodopa or agents such as clonidine, arginine, insulin, propranolol, or glucagon followed by the measurement GH blood levels. Cortisone is given to replace hormone deficiencies that can occur with GH deficiency. Biosynthetic GH is used to treat GH deficiency. DIF: Cognitive Level: Applying REF: MCS: 1499 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 7. The clinic nurse is assessing a child with central precocious puberty. What conditions can cause central precocious puberty? (Select all that apply.) a. Trauma b. Neoplasms c. Radiotherapy d. Exogenous sex hormones e. Primary hypothyroidism ANS: A, B, C Trauma, neoplasms, and radiotherapy can be the cause of central precocious puberty. Exogenous sex hormones and primary hypothyroidism can cause peripheral precocious puberty. DIF: Cognitive Level: Understanding REF: MCS: 1502 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 8. The nurse is planning to admit a 10-year-old child with syndrome of inappropriate antidiuretic hormone (SIADH). What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Polyuria b. Anorexia c. Polydipsia d. Irritability e. Stomach cramps ANS: B, D, E Clinical signs of SIADH are directly related to fluid retention and hyponatremia. When cells in the brain are exposed to too much water as opposed to sodium, swelling occurs. When serum sodium levels are diminished to 120?9?mEq/l, affected children may display anorexia, nausea, vomiting, stomach cramps, irritability, and personality changes. Polyuria and polydipsia are manifestations of diabetes insipidus. DIF: Cognitive Level: Applying REF: MCS: 1504 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. The nurse is planning to admit a 12-year-old with Graves disease (GD). What cailni manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Insomnia b. Irritability c. Tonic rigidity d. Hyperactivity e. Muscle cramps ANS: A, B, D Signs and symptoms of hyperthyroidism develop gradually, with an interval between onset and diagnosis of approximately 6 to 12 months. Clinical features include irritability, hyperactivity, short attention span, tremors, insomnia, and emotional lability. Tonic rigidity and muscle cramps are signs of hypoparathyroidism. DIF: Cognitive Level: Applying REF: MCS: 1507 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 10. The nurse is planning to admit an 8-year-old child with hypoparathyroidism. What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Muscle cramps b. Positive Chvostek sign c. Emotional lability d. Laryngeal spasms e. Short attention span ANS: A, B, D Clinical manifestations of hypoparathyroidism include muscle cramps, positive Chvostek sign, and laryngeal spasms. Emotional lability and short attention span are signs of Graves disease. DIF: Cognitive Level: Applying REF: MCS: 1509 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. What are characteristics of diabetic ketoacidosis? (Select all that apply.) a. Pallor b. Acidosis c. Bradypnea d. Dehydration e. Electrolyte imbalance ANS: B, D, E Characteristics of diabetic ketoacidosis include acidosis, dehydration, and electrolyte imbalance. Respirations are rapid (Kussmaul respirations), not slow, and flushing, not pallor, would occur. DIF: Cognitive Level: Understanding REF: MCS: 1523 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 12. The nurse is preparing to admit a 7-year-old child with type 2 diabetes. What clinical features of type 2 diabetes should the nurse recognize? (Select all that apply.) a. Oral agents are effective. b. Insulin is usually needed. c. Ketoacidosis is infrequent. d. Diet only is often effective. e. Chronic complications frequently occur. ANS: A, C, D The clinical features of type 2 diabetes include the following: orarel aegffeencttsivae, ketoacidosis is infrequent, and diet only is often effective. Insulin is only needed in 20% to 30% of cases and chronic complications occur infrequently. DIF: Cognitive Level: Understanding REF: MCS: 1520 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. The nurse is planning to admit a 14-year-old adolescent with hyperparathyroidism. What clinical manifestations should the nurse expect tovoebisnerthis patient ? (Select all that apply.) a. Polyuria b. Diarrhea c. Hypotension d. Vague bone pain e. Paresthesia in extremities ANS: A, D, E Clinical manifestations of hyperparathyroidism include polyuria, vague bone pain, and paresthesia in the extremities. Constipation, not diarrhea, and hypertension, not hypotension, are manifestations of hyperparathyroidism. DIF: Cognitive Level: Applying REF: MCS: 1510 TOP: NursoicnegssP:rAssessmen t MSC: Client Needs: Physiological Integrity COMPLETION 1. The health care provider has prescribed leuprolide acetate (Lupron Depot) 0.2 mg/kg IM every 4 weeks for a child with precocious puberty. The child weighs 55 lb. The nurse is preparing to administer the dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 5 The correct calculation is: 55 lb/2.2 kg = 25 kg Dose of Lupron Depot is 0.2 mg/kg 0.2 mg 25 = 5 mg DIF: Cognitive Level: Applying REF: MCS: 1502 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The health care provider has prescribed desmopressin acetate (DDAVP) 0.05mg/kg/day PO divided twice daily for a child with diabetes insipidus. The child weighs 110 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer in a whole number. ANS: 1 The correct calculation is: 88 lb/2.2 kg = 40 kg Dose of DDAVP is 0.05 mg/kg/day divided bid 0.05 mg 40 = 2 mg/day 2 mg/2 = 1 mg for one dose DIF: Cognitive Level: Applying REF: MCS: 1503 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The health care provider has prescribed levothyroxine (Synthroid) 4 mcg/kg/day PO for a child with hypothyroidism. The child weighs 77 lb. The nurse is preparing to administer the daily dose. Calculate the dose the nurse should administer in micrograms. Record your answer below in a whole number. ANS: 140 The correct calculation is: 77 lb/2.2 kg = 35 kg Dose of Synthroid is 4 mcg/kg/day 4 mcg 35 = 140 mcg for the daily dose DIF: Cognitive Level: Applying REF: MCS: 1505 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 4. The health care provider has prescribed propylthiouracil (PTU) 7 mg/kg/day PO divided every 12 hours for a child with Graves disease. The child weighs 66 lb. The nurse is preparing to administer the 0800 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 105 The correct calculation is: 66 lb/2.2 kg = 30 kg Dose of PTU is 7 mg/kg/day divided every 12 hours 7 mg 30 = 210 mg 210 mg/2 = 105 mg DIF: Cognitive Level: Applying REF: MCS: 1507 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5. A health care provider prescribes hydrocortisone (Solu-Cortef) 200 mg IV STAT for a child with acute adrenocortical iunfsficiency. T mheedication label states Solu-Cortef 100 mg/2 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer below in a whole number. ANS: 4 Follow the formula for dosage calculation. Desired Volume = ml per dose Available 200 mg 2 ml = 4 ml 100 mg Chapter 32.The Child with Integumentary Dysfunction MULTIPLE CHOICE 1. What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the childs mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed. ANS: A To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good hand washing is imperative in preventing the spread of impetigo. The lesions should be washed gently with a warm soapy washcloth three times a day. Washcloth should not be shared with other members of the family. Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the childs nails to prevent maceration of the lesions. The child may return to school 24 hours after initiation of antibiotic treatment. DIF: Cognitive Level: Comprehension REF: MCS: 634 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 2. When taking a history of a lcdhiw ith lcleulitis, w hich information would be tmpoesrtinent for the nurse to assess? a. Any medication the child is taking b. Enlarged, mobile, and nontender lymph nodes c. Childs urinalysis results d. Recent infections or signs of infection ANS: D Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated. Medication history is important, but the history of recent infections is emroer levant to the diagnosis. Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen, with red streaking of the surrounding area. An abnormal urinalysis result is not usually associated with cellulitis. DIF: Cognitive Level: Comprehension REF: MCS: 635 OBJ: Nursing oPcress Step: A ssessment :MHSC ealth Promotion and Maintenance 3. Which statement made by a parent indicates an understanding about the management of a child with cellulitis? a. I am supposed to continue the antibiotic until the redness and swelling disappear. b. I have been putting ice on my sons arm to relieve the swelling. c. I should call the doctor if the redness disappears. d. I have been putting a warm soak on my sons arm every 4 hours. ANS: D Warm soaks applied everyh4ilhours w e the child aiskaewincrease circulation toethinfected area, relieve pain, and promote healing. The parent should not discontinue antibiotics when signs of infection disappear. To ensure complete healing, the parent should understand that the entire course of antibiotics should be given as prescribed. A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to tahffeected a rea and inhibit the healing process. The disappearance of redness indicates healing and is not a reason to seek medical advice. DIF: Cognitive Level: Application REF: MCS: 635 OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance 4. What should the parents of an infant with thrush (oral candidiasis) be taught about medication administration? a. Give nystatin suspension with a syringe without a needle. b. Apply nystatin cream to the affected area twice a day. c. Give nystatin just before the infant is fed. d. Rub nystatin suspension onto the oral mucous membranes with a gloved finger after feedings. ANS: D It is important toyapt pl nhyestatin s uspension to tahfefected areas, w hichsitsabcecomplished by rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared. Medication may not crehat he affected areas when it is squirted into the infants mouth. Rubbing the suspension onto the gum ensures contact with the affected areas. Nystatin cream is used for diaper rash caused by Candida. To prolong contact with the affected areas, the medication should be administered after a feeding. DIF: Cognitive Level: Application REF: MCS: 636 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 5. What beverage should the parents of a child with ringworm be taught to give along with the prescribed griseofulvin (Fulvicin)? a. Water b. A carbonated drink c. Milk d. Fruit juice ANS: C Griseofulvin is insoluble in water. Giving the medication with a high-fat meal or milk increases absorption. Carbonated drinks do not contain fat, which aids in the absorption of griseofulvin. Fruit juice does not contain any fat; fat aids absorption of the medication. DIF: Cognitive Level: Application REF: MCS: 639 OBJ: Nursing oPcress Step: I mplementation MSC: Health Promotion and Maintenance 6. Which assessment iscaabplpelto t chaere of a child with herpetic gingivostomatitis? a. Comparison of range of motion for the upper and lower extremities b. Urine output, mucous membranes, and skin turgor c. Growth pattern since birth d. Bowel elimination pattern ANS: B The child with herpetic gingivostomatitis is at risk for fluid volume deficit. Painful lesions on the mouth nmkaikneg durnipleasant and undesirable, with subsequent dehydration becoming a real danger. An oral herpetic infection does not affect joint function. Herpetic gingivostomatitis is not a chronic disorder that would affect the childs long-term growth pattern. Although constipation could be caused by dehydration, it is more important to assess urine output, skin turgor, and mucous membranes to identify dehydration before constipation is a problem. DIF: Cognitive Level: Comprehension REF: MCS: 641 OBJ: Nursing oPcress Step: A ssessment :MPSC hysiological Integrity 7. Parents of the child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect? a. Nephrotoxicity b. Neurotoxicity c. Ototoxicity d. Bone marrow depression ANS: B Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. Antilice products are not known to be nephrotoxic or ototoxic. Products that treat lice are not known to cause bone marrow depression. DIF: Cognitive Level: Application REF: MCS: 642 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 8. When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of which problem? a. Asthma b. Nephrosis c. Lower respiratory tract infections d. Neurotoxicity ANS: A Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis and up to 80% of children with iactodp ermatitis have asthma or allergic rhinitis. Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis. There is no link between lower respiratory tract infections and atopic rde matitis. Atopic dermatitis does not have a relationship to neurotoxicity. DIF: Cognitive Level: Comprehension REF: MCS: 630 OBJ: Nursing oPcress Step: A ssessment :MPSC hysiological Integrity 9. What should the nurse teach an adolescent who is taking tretinoin (Retin-A) for treatment acne? a. The medication should be taken with meals. b. Apply sunscreen before going outdoors. c. Wash with benzoyl peroxide before application. d. The effect of the medication should be evident within 1 week. ANS: B Tretinoin causes photosensitivity and sunscreen should be applied before sun exposure. Tretinoin is a topical medication. Application is not affected by meals. If applied together, benzoyl peroxide and tretinoin have ereddeufcfectiveness a nd a potentially irritant effect. Optimal results from tretinoin are not achieved for 3 to 5 months. DIF: Cognitive Level: Application REF: MCS: 645 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance 10. When changing an infants diaper, the nurse notices small bright red papules with satellite lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of which condition? a. Primary candidiasis b. Irritant contact dermatitis c. Intertrigo d. Seborrheic dermatitis ANS: A Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp. DIF: Cognitive Level: Analysis REF: MCS: 636 OBJ: Nursing oPcress Step: A ssessment :MPSC hysiological Integrity 11. The depth of a burn injury may be classified as: a. localized or systemic. b. superficial, superficial partial thickness, deep partial thickness, or full thickness. c. electrical, chemical, or thermal. d. minor, moderate, or major. ANS: B The vocabulary to classify the depth of burn is superficial, partial thickness, or full thickness. These terms refer to the effect of tbhuern i njury. For pexlea,mi s there a reaction inetharea of the burn (localized) or throughout the body (systemic)? Electrical, chemical, or thermal are terms that refer to the cause of the burn injury. Minor, moderate, or major earme ts that r efer to the severity of the burn injury. DIF: Cognitive Level: Comprehension REF: MCS: 651 OBJ: Nursing oPcress Step: A ssessment :MPSC hysiological Integrity 12. What is the major difference between caring for an infant with burns and an adolescent with burns? a. An increased risk of cardiovascular problems in the infant b. A decreased need for caloric intake in the infant c. An increased risk for hypervolemia in the adolescent d. A decreased need for electrolyte replacement in the infant ANS: A The higher proportion of body fluid to body mass in infants increases the risk of cardiovascular problems because of a less effective cardiovascular response to changing intravascular volume. Infants are at an increased risk for protein and calorie deficiency because tshmeyalhlearve muscle mass and lower body fat. Hypovolemia is a risk for all burn patients; however, the risk is higher for the infant than for tahdeolescent. T re hise an increased r isk for electrolyte loss in the infant because of the larger body surface area. DIF: Cognitive Level: Comprehension REF: MCS: 650 OBJ: Nursing oPcress Step: A ssessment :MPSC hysiological Integrity 13. Which procedure is contraindicated in the care of a child with a minor partial-thickness burn injury wound? a. Cleaning the affected area with mild soap and water b. Applying antimicrobial ointment to the burn wound c. Changing dressings daily d. Leaving all loose tissue or skin intact ANS: D All loose skin and tissue should be debrided because it can become a breeding ground for infectious organisms. Cleaning with mild soap and water is important to the healing process. Antimicrobial ointment is used on the burn wound to fight infection. Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed. DIF: Cognitive Level: Comprehension REF: MCS: 653 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 14. The process of burn shock continues until which physiological mechanism occurs? a. Heart rate returns to normal. b. Airway swelling decreases. c. Body temperature regulation returns to normal. d. Capillaries regain their seal. ANS: D Within minutes of the burnriyn,ju the capillary seals are lost with a massive fluid leakage into the surrounding tissue, resulting in burn shock. The process of burn shock continues for approximately 24 to 48 hours, when capillary seals are restored. The heart rate will be increased throughout the healing process because of increased metabolism. Airway swelling subsides over a period of 2 to 5 days after injury. Body temperature regulation will not be normal until healing is well under way. DIF: Cognitive Level: Comprehension REF: MCS: 655 OBJ: Nursing oPcress Step: A ssessment MSC: Physiological Integrity 15. To assess the child with severe burns for adequate perfusion, the nurse monitors which area? a. Distal pulses b. Skin turgor c. Urine output d. Mucous membranes ANS: C Urine output reflects the adequacy of end-organ perfusion. Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion. Skin turgor is often difficult to assess on burn patients because the skin is not intact. Mucous membranes do not reflect end-organ perfusion. DIF: Cognitive Level: Analysis REF: MCS: 655 OBJ: Nursing oPcress Step: A ssessment :MPSC hysiological Integrity 16. Which medication would be best for the nurse to administer before a dressing change for the severely burned child? a. Codeine b. Benadryl c. Morphine d. Acetaminophen ANS: C Morphine is the drug of choice for pain management in the severely burned child. It should be administered intravenously. Codeine may be used to diminish pain between dressing changes. Benadryl is administered to relieve discomfort from itching. Acetaminophen can be given for discomfort between painful procedures. DIF: Cognitive Level: Application REF: pp. 654-655 OBJ: Nursing Process Step: Planning MSC: Physiological Integrity 17. Which nursing assessment and care holds the highest priority in the initial care of a child with a major burn injury? a. Establishing and maintaining the childs airway b. Establishing and maintaining intravenous access c. Insertion of a catheter to monitor hourly urine output d. Insertion of a nasogastric tube into the stomach to supply adequate nutrition ANS: A Establishing and maintaining the childs airway are always the priority focus for assessment and care. Establishing intravenous access is the second priority in this situation, after the airway has been established. Inserting a catheter and monitoring hourly urine output are the third most important nursing intervention. Nasogastric feedings are not begun initially on a child with major or severe burns. The initial assessment and care ufosc ABCs. DIF: Cognitive Level: Analysis REF: MCS: 655 faorc hild with major burn injuries are the OBJ: Nursing Process Step: Planning MSC: Physiological Integrity MULTIPLE RESPONSE 1. A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan? Select all that apply. a. Clean the diaper area gently after every diaper change with a mild soap. b. Use a protective ointment to clean dry intact skin. c. Use a steroid cream after each diaper change. d. Use rubber or plastic pants over the diaper. e. Wash cloth diapers in hot water with a mild soap and double rinse. ANS: A, B, E Prompt, gentle cleaning with water and mild soap (Dove, Neutrogena Baby Soap) after each voiding or defecation rids the skin of ammonia and other irritants and decreases the chance of skin breakdown and infection. A bland, protective ointment (A&D, Balmex, Desitin, zinc oxide) can be applied to clean, dry, intact skin to help prevent diaper rash. If cloth diapers are laundered at home, the parents should wash them in hot water, using a mild soap and double rinsing. Occlusion increases the risk of systemic absorption of steroid; thus steroid creams are rarely used for diaper dermatitis because the diaper functions as an occlusive dressing. Rubber or plastic pants increase skin breakdown by holding in moisture and should be used infrequently. DIF: Cognitive Level: Application REF: MCS: 630 OBJ: Nursing oPcress Step: I mplementation MSC: Health Promotion and Maintenance 2. A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply. a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes. ANS: C, D, E An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix Creme Rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in antilice shampoo or hot water [greater than 60 C (140 F)] for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting. Chapter 33.The Child with Musculoskeletal or Articular Dysfunction MULTIPLE CHOICE 1. An 8-year-old child is hit by a motor vehicle in the school parking lot. The school nurse notes that the child is responding to verbal stimulation but is not moving his extremities when requested. What is the first action the nurse should take? a. Wait for the childs parents to arrive. b. Move the child out of the parking lot. c. Have someone notify the emergency medical services (EMS) system. d. Help the child stand to return to play. ANS: C The child was involved in a motor vehicle collision and at this time is not able to move his extremities. The child needs immediate attention at a hospital for assessment of the possibility of a spinal cord injury. Because the child cannot move his extremities, the child should not be moved until his cervical and vertebral spines are stabilized. The EMS team can appropriately stabilize the spinal column for trat.nAspltohrough it is important to notify the parents, the EMS system should be activated and transport arranged for serious injuries. The only indication to move the child is to prevent further trauma. DIF: Cognitive Level: Analyzing REF: MCS: 1545 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The nurse stops to assist an adolescent who has experienced severe trauma when hit by a motorcycle. The emergency medical system (EMS) has been activated. The first person who provided assistance applied a tourniquet to the childs leg ubseecaof arterial bleeding. What should the nurse do related to the tourniquet? a. Loosen the tourniquet. b. Leave the tourniquet in place. c. Remove the tourniquet and apply direct pressure if bleeding is still present. d. Remove the tourniquet every 5 minutes, leaving it off for 30 seconds each time. ANS: B A tourniquet is applied only as a last resort, and then it is left in place and not loosened until definitive treatment is available. Atefr the tourniquet is applied, skin and tissue necrosis occur below the site. Loosening or removing the tourniquet allows toxins from the tissue necrosis to be released into the circulation. This can induce systemic, deadly tourniquet shock. DIF: Cognitive Level: Analyzing REF: MCS: 1545 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. What is a physiologic effect of immobilization on children? a. Metabolic rate increases. b. Venous return improves because the child is in the supine position. c. Circulatory stasis can lead to thrombus and embolus formation. d. Bone calcium increases, releasing excess calcium into the body (hypercalcemia). ANS: C The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. With the loss of muscle contraction, there is a decreased venous return to the heart. Calcium leaves the bone during immobilization, leading to bone demineralization and increasing the calcium ion concentration in the blood. DIF: Cognitive Level: Understanding REF: MCS: 1549 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. What condition can result from the bone demineralization associated with immobility? a. Osteoporosis b. Pooling of blood c. Urinary retention d. Susceptibility to infection ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Pooling of blood is a result of the cardiovascular effects of immobilization. Urinary retention is secondary to the effect of immobilization on the urinary tract. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems. DIF: Cognitive Level: Understanding REF: MCS: 1554 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. What measure is important ingminagna hypercalcemia in a child who is immobilized? a. Provide adequate hydration. b. Change position frequently. c. Encourage a diet high in calcium. d. Provide a diet high in calories for healing. ANS: A Vigorous hydration is indicated to prevent problems with hypercalcemia. Suggested intake for an adolescent is 3000 to 4000 ml/day of fluids. Diuretics are used to promote the removal of calcium. Changing position is important for skin and respiratory concerns. Calcium in the diet is restricted when possible. A high-protein diet served as frequent snacks with favored foods is recommended. A high-calorie diet without adequate protein will not promote healing. DIF: Cognitive Level: Understanding REF: MCS: 1554 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. The nurse is caring for an immobilized preschool child. What intervention is helpful during this period of immobilization? a. Encourage wearing pajamas. b. Let the child have few behavioral limitations. c. Keep the child away from other immobilized children if possible. d. Take the child for a walk by wagon outside the room. ANS: D Transporting the child outside of the room by stretcher, wheelchair, or wagon increases environmental stimuli and provides social contact. Street clothes are preferred for hospitalized children. This decreases the sense of illness and disability. The child needs appropriate limits for both adherence to the medical regimen and developmental concerns. It is not necessary to keep the child away from other immobilized children. DIF: Cognitive Level: Analyzing REF: MCS: 1563 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 7. The nurse is teaching parents the proper use of a hipkneeanklefoot orthosis (HKAFO) for their 4-year-old child. The parents demonstrate basic essential wknloedge by making what statement? a. Alcohol will be used twice a day to clean the skin around the brace. b. Weekly visits to the orthotist are scheduled to check screws for tightness. c. Initially, a burning sensation is expected and the brace should remain in place. d. Condition of the skin in contact with the brace should be checked every 4 hours. ANS: D This type of brace has several contact points with the childs skin. To minimize the risk of skin breakdown and facilitate use of the brace, vigilant skin monitoring is necessary. Alcohol should not be used on the skin. It is drying. Parents are capable of checking and tightening the screws when necessary. If a burning sensation occurs, the brace should be removed. If several complaints of burning occur, the orthotist should be contacted. DIF: Cognitive Level: Applying REF: MCS: 1565 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 8. Immobilization causes what effect on metabolism? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased levels of stress hormones ANS: B Immobilization causes a decreasedamboeltic rate w ith swloing of all systems and a decreased food intake. Immobilization leads to hypercalcemia and a negative nitrogen balance secondary to muscle atrophy. eDaescerd production of stress hormones occurs with decreased physical and emotional coping capacity. DIF: Cognitive Level: Understanding REF: MCS: 1554 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. What finding aisracchteristic of fractures in children? a. Fractures rarely occur at the growth plate site because it absorbs shock well. b. Rapidity of healing is inversely related to the childs age. c. Pliable bones of growing children are less porous than those of adults. d. The periosteum of a childs bone is thinner, is weaker, and has less osteogenic potential compared to that of an adult. ANS: B Healing is more rapid in children. The younger the child, the more rapid the healing process. Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the weakest point of long bones and a frequent site of injury during trauma. Childrens bones are more pliable and porous than those of adults. This allows them to bend, buckle, and break. The greater porosity increases the flexibility of the bone and dissipates and absorbs a significant amount of the force on impact. The adult periosteum is thinner, is weaker, and has less osteogenic potential than that of a child. DIF: Cognitive Level: Understanding REF: MCS: 1568 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 10. A 14-year-old is admitted to the emergency department with a fracture of the right humerus epiphyseal plate through the joint surface. What information does the nurse know regarding this type of fracture? a. It will create difficulty because the child is left handed. b. It will heal slowly because this is the weakest part of the bone. c. This type of fracture requires different management to prevent bone growth complications. d. This type of fracture necessitates complete immobilization of the shoulder for 4 to 6 weeks. ANS: C This type of fracture (Salter type III) can rcoabulseemps with growth i n tahfe fected limb. Early and complete assessment is essential to prevent angular deformities and longitudinal growth problems. The difficulty for the child does not depend on the location at the epiphyseal plate. Any fracture of the dominant arm presents obstacles for the individual. Healing is usually rapid in the epiphyseal plate area. Complete immobilization is not necessary. Often these injuries are surgically repaired with open reduction and internal fixation. DIF: Cognitive Level: Understanding REF: MCS: 1569 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. Parents bring a 7-year-old child to the icclin for evaluation of an injured wrist after a bicycle accident. The parents and child are upset, and the child will not oalwl manineaxtaion of the injured arm. What priority nursing intervention should occur at this time? a. Send the child to radiology so radiography can be performed. b. Initiate an intravenous line and administer morphine for the pain. c. Calmly ask the child to point to where the pain is worst and to wiggle fingers. d. Have the parents hold the child so that the nurse can examine the arm thoroughly. ANS: C Initially, assessment is the priority. Because the child is alert but upset, the nurse should work to gain the childs trust. Initial data are gained by observing the childs ability to move the fingers and to point to the pain. Other important observations at this time are pallor and paresthesia. The child needs to be sent for radiography, but initial assessment data need to be obtained. Sending the child for radiography will increase the childs anxiety, making the examination difficult. It is inappropriate to ask parents to restrain their child. These parents are upset about the injury. If restraint is indicated, the nurse should obtain assistance from other personnel. DIF: Cognitive Level: Applying REF: MCS: 1572 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 12. A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions? a. No restrictions of activity are indicated. b. Elevate casted arm when both upright and resting. c. The shoulder should be kept as immobile as possible to avoid pain. d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours. ANS: B The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous rnet.u The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged. Joints above and below the cast on the affected extremity should be moved. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. DIF: Cognitive Level: Applying REF: MCS: 1566 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 13. The nurse uses the five Ps to assess ischemia in a child with a fracture. What finding is considered a late and ominous sign? a. Petaling b. Posturing c. Paresthesia d. Positioning ANS: C Paresthesia distal to the injuryaosrt cis a n ominous sign that resquimi edimate not ficaition of the practitioner. Permanent muscle and tissue damage can occur within 6 hours. The other signs of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an ominous sign unless pain was increasing or uncontrollable. DIF: Cognitive Level: Applying REF: MCS: 1573 TOP: Nursing Process: Assessment MSC: Client eNdes: Physiologica l Integrity 14. A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub the leg. c. Carefully pick material off the leg. d. Apply powder to absorb the material. ANS: A Simply soaking in the bathtub is usually sufficient for removal of the desquamated skin and sebaceous secretions. Several days may be required to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child. DIF: Cognitive Level: Applying REF: MCS: 1557 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 15. A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a child at home is complex, the nurse should include what instructions for the parents discharge teaching? a. Turn every 8 hours. b. Specially designed car restraints are necessary. c. Diapers should be avoided to reduce soiling of the cast. d. Use an abduction bar between the legs to aid in turning. ANS: B Standard seat belts and car seats may not ebaedrily ada pted for use by children inesocmasts. Specially designed carsseaantd restraints meet safety requirements. The tc hald mus ve position changes much more frequently than every 8 hours. During feeding and play activities, the child should be moved for both physiologic and psychosocial benefit. Diapers and other strategies are necessary to maintain cleanliness. The abduction bar visenr eus ed as an aid for turning. Putting pressure on the bar may damage the integrity of the cast. DIF: Cognitive Level: Applying REF: MCS: 1559 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 16. What is an appropriate nursing intervention when caring for a child in traction? a. Removing adhesive traction straps daily to prevent skin breakdown b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles c. Providing active range of motion exercises to affected extremity three times a day d. Keeping child prone to maintain good alignment ANS: B Traction places stress on the affected bone,tj,oaind muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced onlynwahbe solutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement cisteedxpweith chi ldren. Each time the child moves, the nurse should check to ensure that proper alignment is maintained. DIF: Cognitive Level: Applying REF: MCS: 1562 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 17. The nurse is caring for a hospitalized easdcoelnt whose femur was fractured 18 hours ago. The adolescent suddenly develops chest pain and dyspnea. The nurse should suspect what complication? a. Sepsis b. Osteomyelitis c. Pulmonary embolism d. Acute respiratory tract infection ANS: C Fat emboli are of greatest concern in individuals with fractures of the long bones. Fat droplets from the marrow are transferred to the general circulation, where they are transported to the lung or brain. This type of embolism usually occurs within the second 12 hours after the injury. Sepsis would manifest with fever and lethargy. Osteomyelitis usually is seen with pain at the site of infection and fever. A child with an acute respiratory tract infection would have nasal congestion, not chest pain. DIF: Cognitive Level: Analyzing REF: MCS: 1575 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. What statement risreccot r egarding sports injuries during adolescence? a. Conditioning does not help prevent many sports injuries. b. The increase in strength and vigor during adolescence helps prevent injuries related to fatigue. c. More injuries occur during organized athletic competition than during recreational sports participation. d. Adolescents may not possess insight and judgment to recognize when a sports activity is beyond their capabilities. ANS: D Injuries occur when the adolescents body is not suited to the sport or when he or she lacks the insight and judgment to recognize that an activity exceeds his or her physical abilities. More injuries occur nwhane ado lescents muscles and body systems (respiratory anddciaorvascular) are not conditioned to endure physical stress. Injuries do not occur from fatigue but rather from overuse. All sports have the nptoitael f or injury to the participant, whether the youngster engages in serious competition or in sports for recreation. More injuries occur during recreational sports than during organized athletic competition. DIF: Cognitive Level: Understanding REF: MCS: 1576 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 19. The middle school nurse is speaking to parents about prevention of injuries as a goal of the physical education program. How should the goal be achieved? a. Use of protective equipment at the familys discretion b. Education of adults to recognize signs that indicate a risk for injury c. Sports medicine program to help student athletes work through overuse injuries d. Arrangements for multiple sports to use same athletic fields to accommodate more children ANS: B Adults close to sports activities need to be aware of the early warning signs of fatigue, dehydration, and risk for injury. School policy should require mandatory use of protective equipment. Proper sports medicine therapy does not support working through overuse injuries. Too many students involved in different activities create distractions, which contribute to the child losing focus. This is a contributing factor to injury. DIF: Cognitive Level: Applying REF: MCS: 1584 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 20. A young girl has just injured her ankle at school. In addition to notifying the childs parents, what is the most appropriate, immediate action by the school nurse? a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a position of comfort. d. Obtain parental permission for administration of acetaminophen or aspirin. ANS: A Soft tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, acnodmhparveession applied. The nurse observes for tehdeem a while placing a cold pack. The applying of ice can reduce the severity of the injury. Maintaining the ankle at a position elevated above the heart is important. The nurse helps the child be comfortable with this requirement. The nurse obtains parental permission for administration of acetaminophen or aspirin after ice and rest are assured. DIF: Cognitive Level: Applying REF: MCS: 1601 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 21. A student athlete was injured during a basketball game. The nurse observes significant swelling. The player states he thought he heard a pop, that the pain is pretty bad, and that the ankle feels as if it is coming apart. Based on this description, the nurse suspects what injury? a. Sprain b. Fracture c. Dislocation d. Stress fracture ANS: A Sprains account for approximately 75% of all ankle injuries in children. A sprain results when the trauma is so seetver hat a ligament is either stretched or partoimallpyleoter lcy torn by the force created as a joint is twisted or wrenched. Joint laxity is the tmvoaslid ind icator of the severity of a sprain. A fracture involves the cross-section of the bone. Dislocations occur when the force of stress on the ligaments disrupts the normal positioning of the bone ends. Stress fractures result from repeated muscular contraction and are seen most often in sports involving repetitive weight bearing such as running, gymnastics, and basketball. DIF: Cognitive Level: Analyzing REF: MCS: 1578 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 22. An adolescent comes to the school nurse after experiencing shin splints during a track meet. What reassurance should the nurse offer? a. Shin splints are expected in runners. b. Ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain. c. It is generally best to run around and work the pain out. d. Moist heat and acetaminophen are indicated for this type of injury. ANS: B Shin splints result when the ligaments tear away from the tibial shaft and cause pain. Actions that have an antiinflammatory ecfft are indicated f or nshtsin. Iscpel,ir est, and NSAIDs are the usual treatment. Shin splints are rarely serious, but they are not expected, and preventive measures are taken. Rest is important to heal the shin splints. Continuing to place stress on the tibia can lead to further damage. DIF: Cognitive Level: Applying REF: MCS: 1579 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 23. The nurse at a summer camp recognizes the signs of heatstroke in an adolescent girl. Her temperature is 40 C (104 F). She is slightly confused but able to drink water. Nursing care while waiting for transport to the hospital should include what intervention? a. Administer antipyretics. b. Administer salt tablets. c. Apply towels wet with cool water. d. Sponge with solution of rubbing alcohol and water. ANS: C Heatstroke is a failure of normal thermoregulatory mechanisms. tThe onse is rapid with initial symptoms of headache, weakness, and disorientation. Immediate care is relocation to a cool environment, removal of clothing, and applying of cool water (wet towels or immersion). Antipyretics are not used because they are metabolized by the liver, which is already not functioning. Salt tablets are not indicated and may be harmful by increasing dehydration. Rubbing alcohol is not used. DIF: Cognitive Level: Applying REF: MCS: 1580 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 24. What is the recommended drink for athletes during practice and competition? a. Sports drinks to replace carbohydrates b. Cold water for gastrointestinal tract rapid absorption c. Carbonated beverages to help with acidbase balance d. Enhanced performance carbohydrateelectrolyte drinks ANS: B Water is recommended for most athletes, who should drink 4 to 8 oz every 15 to 20 minutes. Cold water facilitates rapid gastric emptying and intestinal absorption. Most carbohydrate sports drinks have 6% to 8% carbohydrate, which can cause gastrointestinal upset. Carbonated beverages are discouraged. There is no evidence that these drinks enhance function. DIF: Cognitive Level: Analyzing REF: MCS: 1580 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. The nurse is teaching tghierls varsity spot essential information to include? r s teams about the female athlete triad. Wha s a. They should take low to moderate calcium to avoid hypercalcemia. b. They have strong bones because of the athletic training. c. Pregnancy can occur in the absence of menstruation. d. A diet high in carbohydrates accommodates increased training. ANS: C Sexually active teenagers, redgleass of menstrual status, need to consider contraceptive precautions. Increased calcium (1500 mg) is recommended for amenorrheic athletes. The decreased etrsogen in gi rls with the female athlete triad,lceoduwp ith epnotially inadequate d iet, leads to osteoporosis. Diets high in protein and calories are necessary to avoid potentially long- term consequences of intensive, prolonged exercise programs in pubertal girls. DIF: Cognitive Level: Applying REF: MCS: 1604 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 26. Parents are considering treatment options for their 5-year-old child with Legg-Calv-Perthes disease. Both surgical and conservative therapies are appropriate. They are able to verbalize the differences between the therapies when they make what statement? a. All therapies require extended periods of bed rest. b. Conservative therapy will be required until puberty. c. Our child cannot attend school during the treatment phase. d. Surgical correction requires a 3- to 4-month recovery period. ANS: D Surgical correction involves additional risks of anesthesia, infection, and possibly blood transfusion. The recovery period is only 3 to 4 months rather than the 2 to 4 years of conservative therapies. The use of nonweight-bearing appliances and surgical intervention does not require prolonged bed rest. Conservative therapy is indicated for 2 to 4 years. The child is encouraged to attend school and engage in activities that can be adapted to therapeutic appliances. DIF: Cognitive Level: Applying REF: MCS: 1588 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 27. A 4-year-old child is placed in Buck extension traction for Legg-Calv-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first? a. Reposition the child and notify the practitioner. b. Notify the practitioner of the changes noted. c. Give the child medication to relieve the pain. d. Chart the observations and check the extremity again in 15 minutes. ANS: B The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. This is an emergency condition. Pain medication should be given after the practitioner is notified. The findings should be documented with ongoing assessment. DIF: Cognitive Level: Applying REF: MCS: 1561 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 28. What term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Lordosis c. Kyphosis d. Ankylosis ANS: C Kyphosis is an abnormally increased convex angulation in the curvature of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits. Ankylosis is the immobility of a joint. DIF: Cognitive Level: Understanding REF: MCS: 1585 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 29. When does idiopathic scoliosis become most noticeable? a. In the newborn period b. When the child starts to walk c. During the preadolescent growth spurt d. During adolescence ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. It is seldom apparent before age 10 years. DIF: Cognitive Level: Understanding REF: MCS: 1587 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 30. A preadolescent has been diagnosed with scoliosis. The planned therapy is the use of a thoracolumbosacral orthotic. The preadolescent asks how long she will have to wear the brace. What is the appropriate response by the nurse? a. For as long as you have been told. b. Most preadolescents use the brace for 6 months. c. Until your vertebral column has reached skeletal maturity. d. It will be necessary to wear the brace for the rest of your life. ANS: C Bracing can halt or slow the progress of most curvatures. They must be used continuously until the child reaches skeletal maturity. Telling the child for as long as you have been told does not answer the childs question and does not promote involvement in care. Six months is unrealistic because skeletal maturity is not reached until adolescence. When skeletal growth is complete, bracing is no longer effective. DIF: Cognitive Level: Applying REF: MCS: 1587 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 31. A 17-year-old patient is returning to the rsguical unit after L uque instrumentation for scoliosis repair. In addition to the usual postoperative care, what additional intervention will be needed? a. Position changes are made by log rolling. b. Assistance is needed to use the bathroom. c. The head of the bed is elevated to minimize spinal headache. d. Passive range of motion is instituted to prevent neurologic injury. ANS: A After scoliosis repairiunsg a Luque procedure, the adolescent is turned by log rolling to prevent damage to the fusion and instrumentation. The patient is kept flat in bed for the first 12 hours and is not ambulatory until the second or third postoperative day. A urinary catheterliascepd. The head of the bed is not elevated until the second postoperative day. Range of motion exercises are begun on the second postoperative day. DIF: Cognitive Level: Understanding REF: MCS: 1589 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 32. What is the apryimm ethod of treating osteomyelitis? a. Joint replacement b. Bracing and casting c. Intravenous antibiotic therapy d. Long-term corticosteroid therapy ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus infection. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroid therapy are not indicated for infectious processes. DIF: Cognitive Level: Understanding REF: MCS: 1597 TOP: Nursing ePsrsoc : Implementation MSC: Client Needs: Physiological Integrity 33. What nursing intervention is most appropriate when caring for the child with osteomyelitis? a. Encourage frequent ambulation. b. Administer antibiotics with meals. c. Move and turn the child carefully and gently to minimize pain. d. Provide active range of motion exercises for the affected extremity. ANS: C During the acute phase, any movement of the affected limb causes discomfort to the child. Careful positioning with fthecetaef d limb supported is necessary. Weight bearing is not permitted until healing is lwl eunde r way to avoid pogatihcofl ractures. Invternaous antibiotics are used initially. Food is not necessary with parenteral therapy. Active range of motion would be painful for the child. DIF: Cognitive Level: Applying REF: MCS: 1599 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 34. What statement risuet concerning eoosgtenesis imperfecta (OI)? a. It is easily treated. b. It is an inherited disorder. c. Braces and exercises are of no therapeutic value. d. Later onset disease usually runs a more difficult course. ANS: B OI is a heterogeneous, autosomal dominant disorder characterized by fractures and bone deformity. Treatment is primarily supportive. Several investigational therapies are being evaluated. The primary goal of therapy is rehabilitation. Lightweight braces and splints help support limbs, prevent fractures, and aid in ambulation. The disease is present at birth. Prognosis is affected by the type of OI. DIF: Cognitive Level: Understanding REF: MCS: 1600 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 35. What is a major goal for the therapeutic management of juvenile idiopathic arthritis (JIA)? a. Control pain and preserve joint function. b. Minimize use of joint and achieve cure. c. Prevent skin breakdown and relieve symptoms. d. Reduce joint discomfort and regain proper alignment. ANS: A The goals of therapy are to control pain, preserve joint range of motion and function, minimize the effects of inflammation, and promote normal growth and development. There is no cure for JIA at this time. Skin breakdown is not an issue for most children with JIA. Symptom relief and reduction in discomfort are important. When the joints are damaged, it is often irreversible. DIF: Cognitive Level: Understanding REF: MCS: 1602 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 36. A cldhiwith juve nile idiopathic arthritis (JIA) is rstead on a rnooindsatleantiinflammatory drug (NSAID). What nursing consideration should be included? a. Monitor heart rate. b. Administer NSAIDs between meals. c. Check for abdominal pain and bloody stools. d. Expect inflammation to be gone in 3 or 4 days. ANS: C NSAIDs are the firsint-el dr ugs dusien J IA.ePnotital side effects include gastrointestinal (GI), renal, and hepatic side effects. The child is at risk for GI bleeding and elevated blood pressure. The heart rate is not affected by this drug class. NSAIDs should bene wgiv ith meals to minimize gastrointestinal problems. The antiinflammatory response usually takes 3 weeks before effectiveness can be evaluated. DIF: Cognitive Level: Applying REF: MCS: 1605 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 37. What is an important nursing consideration when caring for a child with juvenile idiopathic arthritis (JIA)? a. Apply ice packs to relieve acute swelling and pain. b. Administer acetaminophen to reduce inflammation. c. Teach the child and family correct administration of medications. d. Encourage range of motion exercises during periods of inflammation. ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not haanvteiinflammatory Range of motion exercises should not be done during periods of inflammation. DIF: Cognitive Level: Applying REF: MCS: 1605 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity eecftfs. 38. What needs to be included as essential teaching for adolescents with systemic lupus erythematosus (SLE)? a. High calorie diet because of increased metabolic needs b. Home schooling to decrease the risk of infections c. Protection from sun and fluorescent lights to minimize rash d. Intensive exercise regimen to build up muscle strength and endurance ANS: C The photosensitive rash is a major concern for individuals with SLE. Adolescents who spend time outdoors need to use sunscreens with a high SPF, hats, and clothing. Uncovered fluorescent lights can also cause a photosensitivity reaction. The diet should be sufficient in calories and nutrients for growth and development. The use of steroids can cause increased hunger,trinesgul in weight gain. This can present additional emotional issues for the adolescent. Normal functions should be maximized. The individual with SLE is encouraged to attend school and participate in peer activities. A balance of rest and exercise is important; excessive exercise is avoided. DIF: Cognitive Level: Applying REF: MCS: 1609 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 39. The nurse is teaching tphaerent of ar4-ye -old child with a cast on the arm about care at home. What statement by the parent indicates a correct understanding of the teaching? a. I should have the affected limb hang in a dependent position. b. I will use an ice pack to relieve the itching. c. I should avoid keeping the injured arm elevated. d. I will expect the fingers to be swollen for the next 3 days. ANS: B Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent position for more than 30 minutes. The affected arm should be kept elevated as much as possible. If there is swelling or redness of the fingers, the parent should notify the health care provider. DIF: Cognitive Level: Applying REF: MCS: 1559 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 40. The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. What statement by the parent would indicate a correct understanding of the teaching? a. I should gently massage the skin under the straps once a day to stimulate circulation. b. I will apply a lotion for sensitive skin under the straps after my baby has been given a bath to prevent skin irritation. c. I should remove the harness several times a day to prevent contractures. d. I will place the diaper over the harness, preferably using a superabsorbent disposable diaper that is relatively thin. ANS: A To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a Pavlik harness, the parent should gently massage the skin under the straps once a day to stimulate circulation. eThparent sho uld not apply lotions or powder because this could irritate the skin. The parent should not remove the harness, except during a bath, and should place the diaper under the straps. DIF: Cognitive Level: Applying REF: MCS: 1591 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 41. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what should the nurse explain? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk. ANS: C Serial casting is begun tslhyoarfter birtho,re disbcehfarge from the nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) tooadcactoemthme rapid growth of early ainnfcy. Serial casting is the preferredattrme ent. S urgical intervention is done only if serial casting is not successful. Children do not improve without intervention. DIF: Cognitive Level: Understanding REF: MCS: 1597 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 42. An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a functional prosthetic device? a. As soon as possible after birth b. When the infant is developmentally ready to stand up c. At about ages 12 to 15 months, when most children are walking d. At about 4 years, when the healthy limb is not growing so rapidly ANS: B An infant should be fitted with a functional prosthetic leg when the infant is developmentally ready to pull to a standing position. fWanhten the in begins limb exploration, a soft prosthesis can be used. The child should begin using the prosthesis as part of his or her normal development. This will match the infants motor readiness. DIF: Cognitive Level: Analyzing REF: MCS: 1552 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 43. The nurse knows that parents need further teaching with regard to the treatment of congenital clubfoot when they state what? a. Well keep ethcast d ry. b. Were happy this is the only cast our baby will need. c. Well watch for any swelling of the foot while the cast is on. d. Were getting a special car seat to accommodate the cast. ANS: B The common approach to clubfoot management and treatment is the Ponseti method. Serial casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along with placement of serial long-leg casts allow for gradual repositioning of the foot. The extremity or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. If parents state that this is the only cast the infant will need, they need further teaching. DIF: Cognitive Level: Applying REF: MCS: 1597 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 44. A cldhihas jus t returned from surgery fror epair of a fractured femur. The child has a long- leg cast on. The toes on the leg with the cast are edematous, but they have color, sensitivity, and movement. What action should the nurse take? a. Call the health care provider to report the edema. b. Elevate the foot and leg on pillows. c. Apply a warm moist pack to the foot. d. Encourage movement of toes. ANS: B During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications (compartment syndrome). One measure to reduce the likelihood of this problem is to elevate the body part and thereby increase venous return. The health care provider does not need to be notified because edema is expected and warm moist packs will not decrease the edema. The child should mthoevtoees, bu t that will pnort hel the edema. DIF: Cognitive Level: Applying REF: MCS: 1559 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 45. After spinal fusion surgery the nurse should check for signs of what? a. Seizure activity b. Increased intracranial pressure c. Impaired color, sensitivity, and movement to the lower extremities d. Impaired pupillary response during neurologic checks ANS: C educe In addition to the usual postoperative assessments of wound, circulation, and vital signs, the neurologic status of the tpraetmieintitesserxe quires special oatmtepnttiroenc.oPgnr ition of any neurologic impairment mis pierative because delayed paralysis may develop that requires surgical intervention. DIF: Cognitive Level: Applying REF: MCS: 1589 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 46. What should the nurse plan for an immobilized child in cervical traction to prevent deep vein thrombosis (DVT)? a. Elevate the childs legs. b. Place a foot cradle on the bed. c. Place a pillow under the childs knees. d. Assist the child to dorsiflex the feet and rotate the ankles. ANS: D For a child who is immobilized, circulatory stasis and DVT development are prevented by instructing patients to change positions frequently, dorsiflex their feet and rotate the ankles, sit in a bedside chair periodically, or ambulate smeevserdaaliltiy. Elevating the legs or placing a foot cradle on the bed will not prevent DVTs. A pillow under the knee would impair circulation, not improve it. DIF: Cognitive Level: Applying REF: MCS: 1551 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 47. The nurse is teaching tahcahicladswt aibout cast r emoval. What should the nurse teach the child about ocavsatl?rem a. The cast cutter will be a quiet machine. b. You will feel cold as the cast is removed. c. You will feel a tickly sensation as the cast is removed. d. The cast cutter cuts through the cast like a circular saw. ANS: C Cutting the cast otoverem liiteovreto re tightness is frequentlytaenfirniggh experience for children. They fear the sound of the cast cutter and are terrified that their flesh, as well as the cast, will be cut. Because it works by vibration, a cast cutter cuts only the hard surface of the cast. The oscillating blade vibrates back and forth very rapidly and will not cut when placed lightly on the skin. Children have described it as producing a tickly sensation. DIF: Cognitive Level: Applying REF: MCS: 1557 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 48. A 3-year-old child has a femoral shaft fracture. The nurse recognizes that the approximate healing time for this child is how long? a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks ANS: B The approximate healing times for a femoral shaft fracture are as follows: neonatal period, 2 to 3 weeks; early childhood, 4 weeks; later childhood, 6 to 8 weeks; and adolescence, 8 to 12 weeks. DIF: Cognitive Level: Understanding REF: MCS: 1570 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 49. The nurse is teaching ainnft ocaprea t entrs with an i nfant who has been diagnosed with osteogenesis imperfecta (OI). What should the nurse include in the teaching session? a. Bisphosphonate therapy is not beneficial for OI. b. Physical therapy should be avoided as it may cause damage to bones. c. Lift the infant by the buttocks, not the ankles, when changing diapers. d. The infant should meet expected gross motor development without assistive devices. ANS: C Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. Bisphosphonate and physical therapy are beneficial for OI. Lightweight braces will be used when the child starts to ambulate. DIF: Cognitive Level: Applying REF: MCS: 1601 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. In teaching a 16-year-old adolescent who was recently diagnosed with systemic lupus erythematosus (SLE), what statements should the nurse include? (Select all that apply.) a. You should use a moisturizer with a sun protection factor (SPF) of 30. b. You should avoid pregnancy because this can cause a flare-up. c. You should not receive any immunizations in the future. d. You may need to be on a low-protein, high-carbohydrate diet. e. You should expect to lose weight while taking steroids. f. You may need to modify your daily recreational activities. ANS: A, B, F Teaching for an adolescent with SLE should foster adaptation and self-advocacy and include using a moisturizer with an SPF of 30, avoiding pregnancy because it can produce a flare-up, and modifying recreational activities but continuing with daily exercise as an essential part of the treatment plan. The adolescent should continue to receive immunizations as scheduled, should expect to gain weight while on steroid therapy, and would not have a specialized diet. DIF: Cognitive Level: Analyzing REF: MCS: 1610 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 2. The nurse is caring for a child immobilized because of Russel traction. What interventions should the nurse implement to prevent renal calculi? (Select all that apply.) a. Monitor output. b. Encourage the patient to drink apple juice. c. Encourage milk intake. d. Ensure adequate fluids. e. Encourage the patient to drink cranberry juice. ANS: A, D, E To prevent renal calculi in a child who is immobilized, a nurse should monitor output; ensure adequate fluids; and encourage cranberry juice, which acidifies urine. Apple juice and milk alkalize the urine, so they should not be encouraged. DIF: Cognitive Level: Applying REF: MCS: 1561 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The nurse is assisting cwaitihonappli of a synthetic cast ontha cahfirladcwtuired hu merus. What are the advantages of a synthetic cast over a plaster of Paris cast? (Select all that apply.) a. Less bulky b. Drying time is faster c. Molds readily to body part d. Permits regular clothing to be worn e. Can be cleaned with small amount of soap and water ANS: A, B, D, E The advantages of synthetic casts over plaster of Paris casts are that they are less bulky, dry faster, permit regular clothes to be worn, and can be cleaned. Plaster of Paris casts moldirlyead to a body part, but synthetic casts do not mold easily to body parts. DIF: Cognitive Level: Analyzing REF: MCS: 1558 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 4. A child has had a short-arm synthetic cast applied. What should the nurse teach to the child and parents about cast care? (Select all that apply.) a. Relieve itching with heat. b. Elevate the arm when resting. c. Observe the fingers for any evidence of discoloration. d. Do not allow the child to put anything inside the cast. e. Examine the skin at the cast edges for any breakdown. ANS: B, C, D, E Cast care involves elevating the arm, observing the fingers for evidence of discoloration, not allowing the child to put anything inside the cast, and examining the skin at the edges of the cast for any breakdown. Ice, not heat, should be applied to relieve itching. DIF: Cognitive Level: Applying REF: MCS: 1559 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 5. The nurse is conducting preoperative teaching to parents and their child about an external fixation device. What should the nurse include in the teaching session? (Select all that apply.) a. Pin care b. Crutch walking c. Modifications in activity d. Observing pin sites for infection e. Full weight bearing will be allowed after 24 hours ANS: A, B, C, D The device is attached surgically by securing a series of external full or half rings to the bone with wires. Children and parents should be instructed in pin care, including observation for infection and loosening of pins. Partial weight bearing is allowed, and the child needs to learn to walk with crutches. Alterations in activity include modifications at school and in physical education. Full weight bearing is not allowed until the distraction is completed and bone consolidation has occurred. DIF: Cognitive Level: Applying REF: MCS: 1562 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 6. The nurse is caring for a 14-year-old child with systemic lupus erythematous (SLE). What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Arthralgia b. Weight gain c. Polycythemia d. Abdominal pain e. Glomerulonephritis ANS: A, D, E Clinical manifestations of SLE include arthralgia, abdominal pain, and glomerulonephritis. Weight loss, not gain, and anemia, not polycythemia, are manifestations of SLE. DIF: Cognitive Level: Analyzing REF: MCS: 1608 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 7. The nurse is caring for a 14-year-old child with juvenile idiopathic arthritis (JIA).tWha clinical manifestations should the nurse expect tovoeb?se(Srelect all that apply.) a. Erythema over joints b. Soft tissue contractures c. Swelling in multiple joints d. Morning stiffness of the joints e. Loss of motion in the affected joints ANS: B, C, D, E Whether single or multiple joints are involved, stiffness, swelling, and loss of motion develop in the affected joints in JIA. The swelling results from soft tissue edema, joint uefsfion, and synovial thickening. The affected joints may be warm and tender to the touch, but it is not uncommon for pain not to be reported. The limited motion early in the disease is a result of muscle spasm and joint inflammation; later it is caused by ankylosis or soft tissue contracture. Morning stiffness of the (josint ) is characteristic and present on ainrigs in the nmionrg or after inactivity. Erythema is not typical, and a warm, painful, red joint is always suspect for infection. DIF: Cognitive Level: Analyzing REF: MCS: 1602 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. The school nurse recognizes that the adverse effects of performance-enhancing substances can include what? (Select all that apply.) a. Depression b. Dehydration c. Hypotension d. Aggressiveness e. Changes in libido ANS: A, D, E Mood changes have been observed as adverse effects of using performance-enhancing substances, including aggressiveness, changes in libido, depression, anxiety, and psychosis. Fluid retention, not dehydration, and hypertension, not hypotension, are adverse effects of performance-enhancing substances. DIF: Cognitive Level: Analyzing REF: MCS: 1582 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity COMPLETION 1. The health care provider has prescribed sulfasalazine (Azulfidine) 5 mg/kg PO per dose twice a day for a child with juvenile arthritis. The child weighs 55 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 125 The correct calculation is: 55 lb/2.2 kg = 25 kg Dose of Azulfidine is 5 mg/kg 5 mg 25 = 125 mg Chapter 34.The Child with Neuromuscular or Muscular Dysfunction MULTIPLE CHOICE 1. What is the most common cause of cerebral palsy (CP)? a. Central nervous system (CNS) diseases b. Birth asphyxia c. Cerebral trauma d. Neonatal encephalopathy ANS: D Approximately 80% of CP is caused by unknown prenatal causes. Neonatal encephalopathy in term and preterm infants is believed to play a significant role in the development of CP. CNS diseases such as meningitis or encephalitis can result in CP. Birth asphyxia does contribute to some cases of CP. Cerebral trauma, including shaken baby syndrome, can result in CP. DIF: Cognitive Level: Understanding REF: MCS: 1632 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 2. Spastic cerebral palsy (CP) is characterized by which clinical manifestations? a. Athetosis, dystonic movements b. Tremors, lack of active movement c. Hypertonicity; poor control of posture, balance, and coordinated motion d. Wide-based gait; poor performance of rapid, repetitive movements ANS: C Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic CP. Athetosis and dystonic movements are part of the classification of dyskinetic or athetoid CP. Tremors and lack of active movement may indicate other neurologic disorders. A wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic CP. DIF: Cognitive Level: Understanding REF: MCS: 1619 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 3. What type of cerebral palsy (CP) ihsetmost common type? a. Ataxic b. Spastic c. Dyskinetic d. Mixed type ANS: B Spastic CP is the most common clinical type. Early manifestations are usually generalized hypotonia, or decreased tone that lasts for a few weeks or may extend for months or as long as 1 year. It is replaced by increased stretch reflexes, increased muscle tone, and weakness. Ataxic, dyskinetic, and mixed type are less common forms of CP. DIF: Cognitive Level: Understanding REF: MCS: 1619 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. The nptasreof an infant with rceebral palsy ( CP) ask the nurse if their child will have cognitive impairment. The nurses response should be based on which knowledge? a. Affected children have some degree of cognitive impairment. b. Around 20% of affected children have normal intelligence. c. About 45% of affected children have normal intelligence. d. Cognitive impairment is expected if motor and sensory deficits are severe. ANS: C Children with CP have a wide range of intelligence, and 40% to 50% are within normal limits. A large percentage of children with CP do not have mental impairment. Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise. DIF: Cognitive Level: Applying REF: MCS: 1620 TOP: Integrated Process: Teaching/Learning MSC: Client eNdes: Physiologica l Integrity 5. Gingivitis is a common problem in children wh ict measure should be included in the plan of care? re ebral palsy (CP). What preventive a. High-carbohydrate diet b. Meticulous dental hygiene c. Minimum use of fluoride d. Avoidance of medications that contribute to gingivitis ANS: B Meticulous eonrael hygi is essential. Many children with CP have congenital enamel defects, high-carbohydrate diets, poor nutritional intake, and difficulty closing their mouths. These, coupled with the childs spasticity or clonic movements, make oral hygiene difficult. Children with CP have high carbohydrate intake and retention, which contribute to dental caries. Use of fluoride should be encouraged through fluoridated water or supplements and toothpaste. Certain medications such as phenytoin do contribute to gingival hyperplasia. If that is the drug of choice, then meticulous oral hygiene must be used. DIF: Cognitive Level: Applying REF: MCS: 1621 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. What is a major goal of therapy for children hwict re ebral palsy (CP)? a. Cure the underlying defect causing the disorder. b. Reverse the degenerative processes that have occurred. c. Prevent the spread to individuals in close contact with the child. d. Recognize the disorder early and promote optimum development. ANS: D The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to iantta their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious. DIF: Cognitive Level: Understanding REF: MCS: 1621 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. The parents of a child with ispast c cerebral palsyP()Cst ate that their dchsiel eomha s t ve significant pain. In addition to systemic pharmacologic management, the nurse includes which teaching? a. Patterning b. Positions to reduce spasticity c. Stretching exercises after meals d. Topical analgesics for muscle spasms ANS: B Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy doifaPtreics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not ecfftive for tmheuscle spasms of spastic CP. DIF: Cognitive Level: Applying REF: MCS: 1622 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 8. A child, age 3 years, has cerebral palsy (CP) andpiistahloizsed f or orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. What is the most appropriate nursing action related to feeding this child? a. Bottle or tube feed him a specialized formula until he gains sufficient weight. b. Stabilize his jaw with caregivers hand (either from a front or side position) to facilitate swallowing. c. Place him in a well-supported, semireclining position. d. Place him in a sitting position with his neck hyperextended to make use of gravity flow. ANS: B Jaw control is compromised in many children with CP. More normal control is achieved if the feeder stabilizes the oral mechanisms from the front or side of the face. Bottle or tube feeding will not improve feeding without jaw support. The semireclining position and hyperextended neck position increase the chances of aspiration. DIF: Cognitive Level: Applying REF: MCS: 1625 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 9. An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurses response should be based on which knowledge? a. Most activities such as Girl Scouts cannot be adapted for children with CP. b. After-school activities usually result in extreme fatigue for children with CP. c. Trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP. d. Recreational activities often provide children with CP with opportunities for socialization and recreation. ANS: D After-school and recreational activities serve itmo sutlate childrens interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are padtead f or children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation. DIF: Cognitive Level: Applying REF: MCS: 1626 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 10. A 4-month-old with significant head lag meets the criteria for floppy infant syndrome. A diagnosis of progressive infantile spinal muscular atrophy (Werdnig-Hoffmann disease) is made. What should be included in the nursing care for this child? a. Infant stimulation program b. Stretching exercises to decrease contractures c. Limited physical contact to minimize seizures d. Encouraging parents to have additional children ANS: A Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). An infant stimulation program is essential. Frequent position changes, including changes in environment, provide the child with more physical contacts. Verbal, tactile, and auditory stimulation are also included. Contractures do not occur because of muscular atrophy. Sensation is normal in children with this disorder. Frequent touch is necessary as part of the stimulation. Werdnig-Hoffmann disease is inherited as an autosomal recessive trait. Parents should be referred for genetic counseling. DIF: Cognitive Level: Applying REF: MCS: 1641 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 11. An 8-year-old child is hospitalized with infectious epuorlyitnis (Guillain -Barr syndrome [GBS]). When explaining this disease process to the parents, what should tnhseidneur?rse co a. Paralysis is progressive with little hope for recovery. b. Disease is inherited as an autosomal, sex-linked, recessive gene. c. Disease results from an apparently toxic reaction to certain medications. d. Muscle strength slowly returns, and most children recover. ANS: D Recovery usually begins within 2 to 3 weeks, and most patients regain full muscle strength. The paralysis is progressive with proximal muscle weakness occurring before distal weakness. The recovery of muscle strength occurs in the reverse order of onset of paralysis. Most individuals regain full muscle strength. Better outcomes are associated with youngerSagi es. GB s an immune-mediated disease often associated with a number of viral or bacterial infections or the administration of vaccines. DIF: Cognitive Level: Applying REF: MCS: 1644 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 12. A 12-year-old child with Guillain-Barr syndrome (GBS) is admitted to the apterdici in nstieve care unit. She tells you thyae sterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, which should the next priority assessment be? a. Swallowing ability b. Parental involvement c. Level of consciousness d. Antecedent viral infections ANS: A Assessment of swallowing is essential. Both pharyngeal involvement and respiratory function are usually involved at the same time. The child may require ventilatory support. The inability to swallow also contributes to aspiration pneumonia. Parental involvement is important after the physiologic assessment pislectoem. T he child is answering questions and describing the onset of the illness, wonhsitcrhatdesems he is alert and oriented. rImnfaotion regardteicnegdaent viral infections can be obtained after the child is assessed and stabilized. DIF: Cognitive Level: Applying REF: MCS: 1644 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 13. What statement is most accurate in describing tetanus? a. Inflammatory disease that causes extreme, localized muscle spasm. b. Disease affecting the salivary gland with resultant stiffness of the jaw. c. Acute infectious disease caused by an exotoxin produced by an anaerobic spore- forming, gram-positive bacillus. d. Acute infection that causes meningeal inflammation resulting in symptoms of generalized muscle spasm. ANS: C Tetanus results from an infection by the anaerobic spore-forming, gram-positive iblalucs Clostridium tetani. The organism forms two exotoxins that affect the central nervous system to produce the clinical manifestations of the disease. Tetanus is not an lianmf matory process. T he toxin acts at the neuromuscular junction to produce muscular stiffness and to lower the threshold for lrexf ex citability. It is usually a systemic disease. Initial symptoms are usually a progressive stiffness and tenderness of the muscles of the neck and jaw. The sustained contraction of the jaw- closing muscles provides the name lockjaw. Meningeal inflammation is not the cause of the muscle spasms. DIF: Cognitive Level: Understanding REF: MCS: 1645 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 14. An adolescent whose leg was crushed when she fell off a horse is admitted togtehneceymer department. She has completed the tetanus immunization series, receiving the last tetanus toxoid booster 8 years ago. aWt hca re is necessary for therapeutic management of this adolescent to prevent tetanus? a. Tetanus toxoid booster is needed because of the type of injury. b. Human tetanus immunoglobulin is indicated for immediate prophylaxis. c. Concurrent administration of both tetanus immunoglobulin and tetanus antitoxin is needed. d. No additional tetanus prophylaxis is indicated. The tetanus toxoid booster is protective for 10 years. ANS: A Protective levels of antibody are maintained for at least 10 years. Children with serious atentus - prone wounds, including contaminated, crush, puncture, or burn wounds, should receive a tetanus toxoid booster prophylactically as soon as possible. This adolescent has circulating antibodies. The immunoglobulin is not indicated. DIF: Cognitive Level: Applying REF: MCS: 1645 TOP: NursoicnegssP:rI mplementation MSC: Client Needs: Physiological Integrity 15. During a well-child visit, the hmeorttells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the childs diet. What factor should support this diagnosis? a. Breastfeeding b. Commercial formula c. Infant cereal with honey d. Improperly sterilized bottles ANS: C Ingestion of honey is a risk factor for infant botulism in the United States. Honey should not be given to children younger than the age of 1 year. Botulism is not found with the use of commercial infant sc.erAeal lthough there is a slight rinc ease in botulism in breastfed infants when compared with formula-fed infants, there is not sufficient evidence to support formula feeding as prevention. Thoroughly cleaning bottles used for formula feeding is sufficient for botulism prevention. Inadequate sterilization of home-canned foods can contribute to botulism. DIF: Cognitive Level: Analyzing REF: MCS: 1647 TOP: Integrated Process: Assessment MSC: Client Needs: Physiological Integrity 16. An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, How bad is it? The nurses response should be based on which knowledge? a. Families adjust better to life-threatening injuries when information is given over time. b. Immediate loss of function is indicative of the long-term consequences of the injury. c. Extent and severity of damage cannot be determined for several weeks or even months. d. Numerous diagnostic tests will be done immediately to determine extent and severity of damage. ANS: C The extent and severity of damage cannot be determined initially. The immediate loss of function is caused by anatomic and impaired physiologic function, and improvement may not be evident for weeks or months. It is essential to provide information about the adolescents status to the parents. Immediate treatment information should be provided. Long-term rehabilitation and prognosis can be addressed after the child is stabilized. During the immediate postinjury period, physiologic responses to the injury make an accurate assessment of damage difficult. DIF: Cognitive Level: Applying REF: MCS: 1654 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Itengrity 17. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child? a. Minimizing environmental stimuli b. Administering immunoglobulin c. Monitoring and maintaining systemic blood pressure d. Discussing long-term care issues with the family ANS: C Spinal cord injury patients are physiologically labile, and close monitoring qisuriere d. They may be unstable for tfhierst f ew weeks after the injury. Increased blood pressure may be an indication of autonomic dysreflexia. It is not necessary to minimize environmental stimuli for this type of injury. Spinal cord injury is not an infectious process. Immunoglobulin is not indicated. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover. DIF: Cognitive Level: Applying REF: MCS: 1656 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 18. What functional ability should the nurse expect in a child with a spinal cord lesion at C7? a. Complete respiratory paralysis b. No voluntary function of upper extremities c. Inability to roll over or attain sitting position d. Almost complete independence within limitations of wheelchair ANS: D Individuals who sustain injuries at the C7 level are able to achieve a significant level of independence. Smoe assistanc e tihs nt eeded wi ransfers and lower extremity dressing. Patients are able to roll over in bed and to sit and eat independently. Patients with injuries at C3 or higher have complete respiratory paralysis. Those with injuries at C4 or higher do not have voluntary function of higher extremities. Injuries at C5 or higher prevent rolling over or sitting. DIF: Cognitive Level: Analyzing REF: MCS: 1651 TOP: NursoicnegssP:rAssessment :MCSlCient Needs: Physiological Integrity 19. An adolescent with a spinal cord injury is admitted to a rehabilitation center. Her parents describe her as being angry, hostile, and uncooperative. The nurse should recognize that this is suggestive of which psychosocial state? a. Normal phase of adolescent development b. Severe depression that will require long-term counseling c. Normal response to her situation that can be redirected in a healthy way d. Denial response to her situation that makes rehabilitative efforts more difficult ANS: C During the rehabilitation phase, it is desirable for adolescents to begin to express negative feelings toward the situation. The rehabilitation team can redirect the negative energy toward learning a new way of life. The injury has interrupted the normal adolescent process of achieving independence, triggering these negative behaviors. Severe depression can occur, but it indicates that the child is no longer in denial. Long-term therapy is not indicated. Being angry, hostile, and uncooperative are behaviors that are indications that the adolescent understands the severity of the injury and need for rehabilitation. DIF: Cognitive Level: Applying REF: MCS: 1661 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 20. What statement best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)? a. It has an autosomal dominant inheritance pattern. b. Onset occurs in later childhood and adolescence. c. It is characterized by presence of Gower sign, a waddling gait, and lordosis. d. Disease stabilizes during adolescence, allowing for life expectancy to approximately age 40 years. ANS: C DMD is characterized by a waddling gait and lordosis. Gower sign is a characteristic way of rising from a squatting or sitting position on the floor. DMD is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. Onset occurs usually between ages 3 and 5 years. DMD has a progressive and relentless loss of muscle function until death by respiratory or cardiac failure. DIF: Cognitive Level: Understanding REF: MCS: 1664 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 21. The nurse is preparing a staff education in-sseirvice se on for a group of new graduate nurses who will be working in a long-term care facility for dchreiln; many ofethchildren ha ve cerebral palsy (CP). What statement should the nurse include in the training? a. Children with dyskinetic CP have a wide-based gait and repetitive movements. b. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus. c. Children with hemiplegia CP have mouth muscles and one lower limb affected. d. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria. ANS: B CP has a variety of clinical classifications. sStpica pyr amidal CP includes manifestations such as a positive Babinski sign and ankle clonus; ataxic CP has a wide-based gait eantidtivre movements; hemiplegia CP is characterized by motor dysfunction on one side of the body with upper extremity more affected than lower limbs; and dyskinetic CP involves the pharyngeal and oral muscles, causing drooling and dysarthria. DIF: Cognitive Level: Applying REF: MCS: 1616 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 22. The nurse shouldcstuaspcehild has cerebral palsy (CP) i f tphaerent swayhsat? a. My 6-month-old baby is rolling from back to prone now. b. My 4-month-old doesnt lift his head when on his tummy. c. My 8-month-old can sit without support. d. My 10-month-old is not walking. ANS: B Delayed gross motor development is a universal manifestation of CP. The child shows a delay in all motor accomplishments, and the discrepancy between motor ability andeedxpect achievement tteondinscrease with s uccessive developmental milestones as growth advances. The infant who does not lift his head when on the tummy is showing a gross motor delay, as that is seen at 0 to 3 months. The other statements are within normal growth and development expectations. DIF: Cognitive Level: Analyzing REF: MCS: 1619 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity 23. The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what? a. Playing pat-a-cake with the child b. None so the child does not become overstimulated c. Putting a colorful mobile with music on the bed d. Giving the child a coloring book and crayons ANS: C Incorporating play into the therapeutic program for a child with CP often requires great ingenuity and inventiveness from those involved in the childs care. Objects and toys are chosen for the childs developmental stage to provide needed sensory input using a variety of shapes, forms, and textures. Nurses can help parents integrate therapy into play activities in natural ways. DIF: Cognitive Level: Applying REF: MCS: 1622 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 24. A recommendation to prevent neural tube defects (NTDs) is the supplementation of what? a. Vitamin A throughout pregnancy b. Folic acid for all women of childbearing age c. Folic acid during the first and second trimesters of pregnancy d. Multivitamin preparations as soon as pregnancy is suspected ANS: B The widespread use of folic acid among women of childbearing age has decreaseditdheenicnec NTDs. In the United States, the rates of NTDs have declined from 1.3 per 1000 births in 1990 to 0.3 per 1000 after the introduction of mandatory folic acid supplementation in food in 1998. Vitamin A is not related to the prevention of NTDs. Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy. The NTD is a failure of neural tube closure during early development, the first 3 to 5 weeks. DIF: Cognitive Level: Understanding REF: MCS: 1628 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 25. The nurse is caring for a family whose infant was just born with anencephaly. What is the most important nursing intervention? a. Implement measures to facilitate the attachment process. b. Help the family cope with the birth of an infant with a fatal defect. c. Prepare the family for extensive surgical procedures that will be needed. d. Provide emotional support so the family can adjust to the birth of an infant with problems. ANS: B Anencephaly is the most serious neural tube defect. The infants have antianct br ainstem and, if born alive, may be able to maintain vital functions for a few hours to several weeks. The family requires emotional support and counseling to cope with the birth of an infant with a tfal defect. The parents should be encouraged to hold their infant and provide comfort measures. This facilitates the grieving process because the infant has a limited life expectancy. Infants with anencephaly do not have cerebral hemispheres. There is no surgical correction available for sthi defect. Emotional support is needed as the family adjusts to the birth of a child who has a fatal defect. DIF: Cognitive Level: Applying REF: MCS: 1631 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 26. What refers to a hernial protrusion of a saclike cyst of meninges, spinal fluid, and a portion of the spinal cord with its nerves through a defect in the vertebral column? a. Rachischisis b. Meningocele c. Encephalocele d. Myelomeningocele ANS: D A myelomeningocele has a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. DIF: Cognitive Level: Understanding REF: MCS: 1631 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 27. A woman who is 6 weeks pregnant tells the nurse that she is worried that, even though she is taking folic acid supplements, the baby might have spina bifida because of a family history. The nurses response should be based on what? a. Prenatal detection is not possible yet. b. There is no genetic basis for the defect. c. Chromosome studies done on amniotic fluid can diagnose the defect prenatally. d. Open neural tube defects (NTDs) result in elevated concentrations of - fetoprotein in amniotic fluid. ANS: D Ultrasound scanning and measurement of -fetoprotein may indicate the presence of anencephaly or myelomeningocele. The optimum time for performing this analyzing is between 16 and 18 weeks. Prenatal diagnosis is possible through amniocentesis. A multifactorial origin is suspected, including drugs, radiation, maternal malnutrition, chemicals, and possibly a genetic mutation. Chromosome abnormalities are not present in NTDs. DIF: Cognitive Level: Applying REF: MCS: 1631 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 28. The most important nursing intervention when caring for an infant with myelomeningocele in the preoperative stage is which? a. Take vital signs every hour. b. Place the infant on the side to decrease pressure on the spinal sac. c. Watch for signs that might indicate developing hydrocephalus. d. Apply a heat lamp to facilitate drying and toughening of the sac. ANS: B The spinal sac is protected from damage until surgery iosrmpeerdf. Early gsuicral closure is recommended to prevent local trauma and infection. Monitoring vital signs and watching for signs that might indicate developing hydrocephalus are important interventions, but preventing trauma to the sac is a priority. The sac is kept moist until surgical intervention is done. DIF: Cognitive Level: Applying REF: MCS: 1638 TOP: Nursing Process: Planning MSC: Client eNdes: Physiologica l Integrity 29. Neuropathic bladder disorders are common among children with which disorder? a. Plagiocephaly b. Meningocele c. Craniosynostosis d. Myelomeningocele ANS: D Myelomeningocele is one of the most common causes of neuropathic bladder dysfunction among children. Plagiocephaly is the flattening of a side of the childs head. This is not associated with neuropathic bladder. Children with meningocele usually do not have neuropathic bladder. Craniosynostosis is the premature closure of one or amnoiarel scur neuropathic bladder. tures. It is not associated with DIF: Cognitive Level: Understanding REF: MCS: 1635 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 30. What most accurately describes bowel function in children born with a myelomeningocele? a. Incontinence cannot be prevented. b. Enemas and laxatives are contraindicated. c. Some degree of fecal continence can usually be achieved. d. Colostomy is usually required by the time the child reaches adolescence. ANS: C With a combination of dietary modification, regular toilet habits, and prevention of constipation and pimaction, some degree of fecal continence can usually be achieved. Incontinence can be minimized with the development of a regular bowel training program. A surgical intervention can assist with continence. Enemas and laxatives are part of aibnoinwgepl rtorgram. Colostomies are not indicated in children with myelomeningocele. DIF: Cognitive Level: Understanding REF: MCS: 1637 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 31. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. What is the most appropriate way to position and feed this neonate? a. Prone with the head turned to the side b. On the side c. Supine in an infant carrier d. Supine, with defect supported with rolled blankets ANS: A The prone position with the head turned to the side for feeding is the optimum position for the infant. It protects the spinal sac and allows the infant toebdewf ithout trauma. The side-lying position is avoided preoperatively. It can place tension on the sac and affect hip dysplasia if present. The infant should not be placed in a supine position. DIF: Cognitive Level: Applying REF: MCS: 1638 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 32. A goal for children with spina bifida is to reduce the chance of allergy development. What is a priority nursing intervention? a. Recommend allergy testing. b. Provide a latex-free environment. c. Use only powder-free latex gloves. d. Limit use of latex products as much as possible. ANS: B A latex-free environment is the goal. lTuhdiessinc eliminating the use of latex gloves and other medical devices containing latex. Allergy testing would provide information about whether the allergy has developed. It will not reduce the chances of developing the allergy. Although powder-free latex gloves are less allergenic, latex should not be used. Limiting the use of latex products is one component of providing a latex-free environment, but latex products should not be used. DIF: Cognitive Level: Applying REF: MCS: 1640 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 33. When a child develops latex allergy, which food may also cause an allergic reaction? a. Yeast b. Wheat c. Peanuts d. Bananas ANS: D There are cross-reactions between allergies to latex and to a number of foods such as bananas, avocados, kiwi, and chestnuts. Although yeast, wheat, and peanuts are potential allergens, currently they are not known to cross-react with latex allergy. DIF: Cognitive Level: Analyzing REF: MCS: 1640 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 34. The clinic nurse is assessing infant reflexes. What assessment indicates a persistence of primitive reflexes? a. Tonic neck reflex at 8 months of age b. Palmar grasp at 4 months of age c. Plantar grasp at 9 months of age d. Rooting reflex at 3 months of age ANS: A Persistence of primitive reflexes iesaornlieesotfctlhuees to C P (e.g., obligatory tonic neck reflex at any age or nonobligatory persistence beyond 6 months of age and the persistence or even hyperactivity of the Moro, plantar, and palmar grasp reflexes). The palmar grasp disappears by 6 months, the plantar grasp disappears by 12 months, and the rooting reflex disappears at 4 months, so these are normal findings. DIF: Cognitive Level: Analyzing REF: MCS: 1620 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 35. A toddler with spastic cerebral palsy needs to be transported to the radiology department. What transportation method should the nurse use to take the toddler to the radiology department? a. A stretcher b. A wheelchair c. A wagon with pillows d. Carried in the nurses arms ANS: C A wagon with pillows would support the child with spastic cerebral palsy better than a stretcher or wheelchair. A wagon would give the child a wheelchair experience, so the nurse should not carry the child. DIF: Cognitive Level: Applying REF: MCS: 1643 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 36. What is the rationale for orthopedic surgery for a child with cerebral palsy? a. To cure spasticity b. To improve function c. For cosmetic purposes d. To prevent the need of physical therapy ANS: B Orthopedic surgery dis pursiemarily to improve function rather than for cosmetic purposes and is followed by physical therapy. It will not cure spasticity. DIF: Cognitive Level: Understanding REF: MCS: 1622 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 37. A feeding technique the nurse can teach to parents of a child with cerebral palsy to improve use of the lips and the tongue to facilitate speech is which? a. Feeding pureed foods b. Placing food on the tongue c. Placing food at the side of the tongue d. Placing food directly into the mouth with a spoon ANS: C Feeding techniques such as forcing ltdhet chi o use the lips and tongue in eating facilitate speech. An example of this technique is placing food at the side of the tongue, first one side and then the other, and making the child use the lips to take food from a spoon rather than placing it directly on the tongue. Feeding pureed foods would not encourage use of the lips and tongue. DIF: Cognitive Level: Applying REF: MCS: 1625 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 38. The nurse is teaching the family of an infant with cerebral palsy how to administer a diazepam (Valium) pill by gastrostomy tube. What should the nurse include in the teaching session? a. The pill should be crushed and mixed with a small amount of water. b. The pill should be crushed and mixed with the infants formula. c. After administering the medication, flush the tube with air. d. Before administering the medication, check the placement of the tube. ANS: A Pills may be crushed and mixed with small amounts of water but not other liquids, such as formula or iexlir m edications, because these mayeatchtertotgo f orm a sludge that can interfere with gastrostomy tube function. When crushed pills or tablets are administered, flush the feeding tube with more water after instilling the dissolved pill in water. The tube should not be flushed with air, and placement does not need to be checked because it is directly into the stomach. DIF: Cognitive Level: Applying REF: MCS: 1627 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 39. The nurse is caring for a child with tetanus during the acute phase. What should the nurse plan in the carethfoisr c hild? a. Playing music on a radio b. Giving frequent back rubs c. Providing bright lighting in the room d. Clustering nursing care to limit distractions ANS: D In caring for a child with tetanus during the acute phase, every effort should be made to control or eliminate stimulation from sound, light, and touch. Although a darkened room is ideal, sufficient light sisenetsial so t t ht a he child can be carefully observed; light appears to be less irritating than avtiobry or auditory s timuli. The infant or child is handled as little as possible, and extra effort is expended to avoid any sudden or loud noise to prevent seizures. DIF: Cognitive Level: Applying REF: MCS: 1647 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 40. A mother tells the clinic nurse that she often puts honey on her infants pacifier to soothe the infant. What response should the nurse make to the mother? a. That is a good way to soothe your baby. b. Honey does not have any soothing effects. c. There is still a risk for infant botulism from honey. d. Honey is OK, but it should not be put on the pacifier. ANS: C Although the precise source of Clostridium botulinum spores has not been identified as originating from honey in many cases of infant botulism in the tUendiS tates, it is lslti recommended that honey not be given to infants younger than 12 months because the spores have been found in honey. DIF: Cognitive Level: Applying REF: MCS: 1648 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 41. The enuisrsc aring for a child twhim sthyeania gr avis (MG). What health care prescription should the nurse verify before administering? a. Ceftizoxime (Cefizox) b. Cefotaxime (Claforan) c. Ceftriaxone (Rocephin) d. Garamycin (gentamicin) ANS: D Avoid aminoglycoside antibiotics such as gentamicin because they potentiate MG symptoms. Cefizox, Claforan, and Rocephin are cephalosporin antibiotics. DIF: Cognitive Level: Applying REF: MCS: 1649 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. What findings should the nurse expect to observe in a 7-month-old infant with Werdnig- Hoffman disease? (thSaeltect all apply.) a. Noticeable scoliosis b. Absent deep tendon reflexes c. Abnormal tongue movements d. Failure to thrive e. Prominent pectus excavatum f. Significant leg involvement ANS: B, C, D Clinical manifestations of Werdnig-Hoffman disease in an infant include absent deep tendon reflexes, abnormal tongue movements, and failure to thrive. Scoliosis, prominent pectus excavatum, and significant leg involvement are findings observed in a child with intermediate spinal muscular atrophy. DIF: Cognitive Level: Understanding REF: MCS: 1641 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The nurse is teaching the family with a child with cerebral palsy (CP) strategies to epvr ent constipation. What should the nurse include in the teaching session? (Select all that apply.) a. Increase fluid intake. b. Increase fiber in the diet. c. Administer stool softeners daily as prescribed. d. Increase the amount of dairy products in the diet. e. Allow the child to decide when to try to have a bowel movement. ANS: A, B, C A variety of factors, including decreased mobility, decreased fluid intake, a fear of toileting, poor positioning on the toilet, and lack of fiber intake may be responsible for constipation for a child with CP. Stool softeners, laxatives, and a bowel management program may be required to prevent chronic constipation. The child should be placed on the toilet or encouraged to have a bowel movement at the same time each day. Dairy products can cause constipation. DIF: Cognitive Level: Applying REF: MCS: 1621 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 3. What functional goal should the nurse expect for a child who has a C7 spinal cord injury? (Select all that apply.) a. Able to drive automobile with hand controls b. Complete independence within limitations of a wheelchair c. Can roll over in bed, sit up in bed, and eat independently d. Requires some assistance in transfer and lower extremity dressing e. Ambulation with bilateral long braces using four-point or swing-through crutch gait ANS: B, C, D A child with a C7 spinal cord injury can expect to be completely independent within the limitations of a wheelchair, can roll over in bed, sit up in bed, and eat independently, and will require some assistance in transfer and lower extremity dressing. The ability to drive an automobile with hand controls is a functional goal for a T1 to T10 spinal cord injury. Ambulation with bilateral long braces using four-point or swing-through crutch gait is a functional goal for a T10 to L2 injury. DIF: Cognitive Level: Understanding REF: MCS: 1651 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 4. What functional goal should the nurse expect for a child who has a T1 to T10 spinal cord injury? (Select all that apply.) a. May be braced for standing b. Able to drive automobile with hand controls c. Can manage adapted public transportation d. Some able to use regular public transportation e. Ambulates well, often with short leg braces with or without cane ANS: A, B, C A child with a T1 to T10 spinal cord injury may be braced for standing, is able to drive an automobile with hand controls, and can manage adapted public transportation. The ability to use regular public transportation and ambulation with bilateral long braces using four-point or swing- through crutch gait are functional goals for individuals with a T10 to L2 injury. DIF: Cognitive Level: Understanding REF: MCS: 1651 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 5. The nurse is preparing to admit a 7-year-old child with ataxic cerebral palsy. What clinical manifestations of ataxic cerebral palsy should the nurse expect to observe? (Select all that apply.) a. Wide-based gait b. Rapid, repetitive movements performed poorly c. Slow, twisting movements of the trunk or extremities d. Hypertonicity with poor control of posture, balance, and coordinated motion e. Disintegration of movements of the upper extremities when the child reaches for objects ANS: A, B, E Clinical manifestations of ataxic cerebral palsy include a wide-based gait; rapid, repetitive movements performed poorly; and disintegration of movements of the upper extremities when the child reaches for objects. Slow, twisting movements of the trunk are seen with dyskinetic cerebral palsy, and hypertonicity with poor control of posture, balance, and coordinated motion are seen with spastic cerebral palsy. DIF: Cognitive Level: Applying REF: MCS: 1619 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 6. What are some of the associated disabilities seen with cerebral palsy? (Select all that apply.) a. Visual impairment b. Hearing impairment c. Speech difficulties d. Intellectual impairment e. Associated heart defects ANS: A, B, C, D Some of the disabilities associated with CP are visual impairment, hearing impairment, behavioral problems, communication and speech difficulties, seizures, and intellectual impairment. Additional sensory deficits such as hypersensitivity, hyposensitivity, and balance difficulties may occur in children with CP. DIF: Cognitive Level: Understanding REF: MCS: 1620 TOP: Nursing Process: Assessment :MCSC lient Needs: Physiological Integrity 7. The nurse is preparing to admit a 5-year-old with spina bifida cystica that was below the second lumbar vertebra. What clinical manifestations of spina bifida cystica below the second lumbar vertebra should the nurse expect to observe? (Select all that apply.) a. No motor impairment b. Lack of bowel control c. Soft, subcutaneous lipomas d. Flaccid, partial paralysis of lower extremities e. Overflow incontinence with constant dribbling of urine ANS: B, D, E The clinical manifestations of spina bifida cystica below the second lumbar vertebra include lack of bowel control, flaccid, partial paralysis of lower extremities, and overflow oinnctinence w ith constant dribbling of urine. No motor impairment occurs with spina bifida cystica that was below the third lumbar vertebra, and soft, subcutaneous lipomas occur with spina bifida occulta. DIF: Cognitive Level: Applying REF: MCS: 1633 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 8. The nurse is preparing to admit a 2-year-old child with nspaibi idfa uolctca. W t chlianical manifestations of spina bifida occulta should the nurse expect to observe? (Select all that apply.) a. Dark tufts of hair b. Skin depression or dimple c. Port-wine angiomatous nevi d. Soft, subcutaneous lipomas e. Bladder and sphincter paralysis ANS: A, B, C, D Clinical manifestations of spina ublitfaida occ include dark tufts of hair; skin depression or dimple; port-wine angiomatous nevi; and soft, subcutaneous lipomas. Bladder and sphincter paralysis are present with spina bifida cystica but not occulta. DIF: Cognitive Level: Applying REF: MCS: 1633 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 9. The nurse is preparing to admit a 5-year-old child with a lower motor neuron syndrome. What clinical manifestations of a lower motor neuron syndrome should the nurse expect to observe? (Select all that apply.) a. Loss of hair b. Babinski reflex present c. Skin and tissue changes d. Marked atrophy of atonic muscle e. Hyperreflexia with tendon reflexes exaggerated ANS: A, C, D Clinical manifestations of a lower motor neuron syndrome include loss of hair, skin and tissue changes, and marked atrophy of atonic muscle. Babinski reflex present and hyperreflexia with tendon reflexes exaggerated are manifestations of an upper motor neuron syndrome. DIF: Cognitive Level: Applying REF: MCS: 1652 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 10. The nurse is preparing to admit a 7-year-old child with an upper motor neuron syndrome. What clinical manifestations of an upper motor neuron syndrome should the nurse expect to observe? (Select all that apply.) a. No flexor spasms b. Babinski reflex present c. No wasting of muscle mass d. Marked atrophy of atonic muscle e. Hyperreflexia with tendon reflexes exaggerated ANS: B, C, E Clinical manifestations of an upper motor neuron syndrome include Babinski reflex present, no wasting of muscle mass, and hyperreflexia with tendon reflexes exaggerated. No flexor spasms and marked atrophy of atonic muscle are manifestations of a lower motor neuron syndrome. DIF: Cognitive Level: Applying REF: MCS: 1652 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity 11. The nurse is preparing to admit a 10-year-old child with Duchenne muscular dystrophy. What clinical features of Duchenne muscular dystrophy should the nurse recognize? (Select all that apply.) a. Calf muscle hypertrophy b. Late onset, usually between 6 and 8 years of age c. Progressive muscular weakness, wasting, and contractures d. Loss of independent ambulation by 9 to 12 years of age e. Slowly progressive, generalized weakness during adolescence ANS: A, C, D, E Clinical features of Duchenne muscular dystrophy include calf muscle hypertrophy; progressive muscular weakness; wasting and contractures; loss of independent ambulation by 9 to 12 years of age; and slowly progressive, generalized weakness during adolescence. The onset is early, not late, usually between 3 and 5 years of age. DIF: Cognitive Level: Understanding REF: MCS: 1665 TOP: NursoicnegssP:rAssessment :MCSC lient Needs: Physiological Integrity COMPLETION 1. The health care provider has prescribed dantrolene sodium (Dantrium) 0.5 mg/kg PO once a day for a child with cerebral palsy. The child weighs 55 lb. Calculate the dose the nurse should administer in milligrams. Record your answer below using one decimal place. ANS: 12.5 The correct calculation is: 55 lb/2.2 kg = 25 kg Dose of Dantrium is 0.5 mg/kg given once a day 0.5 mg 25 = 12.5 mg DIF: Cognitive Level: Applying REF: MCS: 1623 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 2. The health care provider has prescribed diazepam (Valium) 0.8 mg/kg/day PO divided q 6 hours for a child with cerebral palsy. The child weighs 110 lb. The nurse is preparing to administer the 1200 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 10 The correct calculation is: 110 lb/2.2 kg = 50 kg Dose of Valium is 30 mg/kg/day divided q 6 hours 0.8 mg 50 = 40 mg/day 40 mg/4 = 10 mg for one dose DIF: Cognitive Level: Applying REF: MCS: 1623 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 3. The health care provider has prescribed neostigmine (Prostigmin) 0.04 mg/kg/per dose SC q 4 to 6 hrs PRN for a child with myasthenia gravis. The child weighs 77 lb. The nurse is preparing to administer a dose. Calculate the dose the nurse should administer in milligrams. Record your answer below using one decimal place. ANS: 1.4 The correct calculation is: 77 lb/2.2 kg = 35 kg Dose of Prostigmin is 0.04 mg/kg/dose 0.04 mg 35 = 1.4 mg DIF: Cognitive Level: Applying REF: MCS: 1648 TOP: NursoicnegssP:rImplementation MSC: Client Needs: Physiological Integrity 4. The health care provider has prescribed oxybutynin (Ditropan) 0.2 mg/kg/day divided bid for a child with myelomeningocele. The child weighs 33 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below using one decimal place. ANS: 1.5 The correct calculation is: 33 lb/2.2 kg = 15 kg Dose of Ditropan is 0.2 mg/kg/day divided bid 0.2 mg 15 = 3 mg 3 mg/2 = 1.5 mg DIF: Cognitive Level: Applying REF: MCS: 1636 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 5. The health care provider has prescribed gabapentin (Neurontin) 30 mg/kg/day divided q 8 hours for a child with cerebral palsy having seizures. The child weighs 110 lb. The nurse is preparing to administer the 1200 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 500 The correct calculation is: 110 lb/2.2 kg = 50 kg Dose of Neurontin is 30 mg/kg/day divided every 8 hours 30 mg 50 = 1500 mg/day 1500 mg/3 = 500 mg for one dose DIF: Cognitive Level: Applying REF: MCS: 1644 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 6. The health care provider has prescribed valproic acid (Depakene) 30 mg/kg/day divided bid for a child with cerebral palsy having seizures. The child weighs 22 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 165 The correct calculation is: 22 lb/2.2 kg = 11 kg Dose of Depakene is 30 mg/kg/day divided bid 30 mg 11 = 330 mg 330 mg/2 = 165 mg for one dose DIF: Cognitive Level: Applying REF: MCS: 1623 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. The health care provider has prescribed carbamazepine (Tegretol) 20 mg/kg/day divided bid for a child with cerebral palsy having seizures. The child weighs 44 lb. The nurse is preparing to administer the 0900 dose. Calculate the dose the nurse should administer in milligrams. Record your answer below in a whole number. ANS: 200 The correct calculation is: 44 lb/2.2 kg = 20 kg Dose of Tegretol is 20 mg/kg/day divided bid 20 mg 20 = 400 mg 400 mg/2 = 200 mg [Show More]

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