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EXAM # 5 RNSG 2201 CH. 23, 24, 25, 26 Chapter 23: The Child with Fluid and Electrolyte Imbalance MULTIPLE CHOICE 1. What substance is released from the posterior pituitary gland and promote... s water retention in the renal system? a. Renin b. Aldosterone c. Angiotensin d. Antidiuretic hormone (ADH) ANS: D ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability 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 a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone. 2. Nurses should be alert for increased fluid 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 to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children. 3. What factor predisposes 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 fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The 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. 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. 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. 6. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms? 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. 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 reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the childs ability to correct the fluid imbalance. 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 of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia. 9. What type of dehydration occurs when the electrolyte deficit exceeds 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 another term for hypertonic dehydration. 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. 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. 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. 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 deficit 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. 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 child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication. 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) has clinical signs 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. 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. 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. 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 site remains intact (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 child to significant trauma. 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. 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 even minute 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. 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 limitations on physical activity are needed. The child is able to participate in all 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 self-administration. The port is placed under the skin. If the child manipulates the device and plays with the actual port, the catheter can be dislodged. 21. The nurse is teaching the family of a child with a long-term central venous 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. 22. What 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 catheters larger than 24 gauge. The use of heparin does not increase the longevity of the venous access device. In 24-gauge catheters, heparin may offer 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. 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. 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 bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the viral destruction of the villi of the small intestine. This results in a smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption. 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 short-chain fatty 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. 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. 27. A school-age child with diarrhea has been rehydrated. 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. 28. A school-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. 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. 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 loss is the most frequent cause of 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. 31. What type of shock is characterized by a hypersensitivity reaction 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 injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. 32. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock? 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. 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. 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. 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 resulting from 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. 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. 37. What is the most immediate threat 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. 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. 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. 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. 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. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration. 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 nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number. ANS: 2 ml 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 IV infusion pump to deliver 1 mcg/kg/min? Fill in the blank. Record your answer in a whole number. ANS: 6 ml/hr 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 ml MATCHING Match the type of skin graft to its definition. a. Allografts- Skin that is obtained from genetically different members of the same species who are free of disease b. Xenografts- Skin that is obtained from members of a different species, primarily pigskin c. Autografts- Tissue obtained from undamaged areas of the patients own body d. Isografts- Histocompatible tissue obtained from genetically identical individuals 1. Tissue obtained from undamaged areas of the patients own body- c. Autografts 2. Histocompatible tissue obtained from genetically identical individuals- d. Isografts 3. Skin that is obtained from genetically different members of the same species who are free of disease- a. Allografts 4. Skin that is obtained from members of a different species, primarily pigskin- b. Xenografts 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. 2. What urine test result is considered abnormal? 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. 3. What diagnostic test allows visualization of renal parenchyma and renal pelvis without exposure to external-beam radiation or radioactive 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 radiation 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. 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 bladder. Urethritis is an inflammation of the urethra. Urosepsis is a febrile urinary tract infection with systemic signs of bacterial infection. Bacteriuria is the presence of bacteria in the urine. 5. The nurse is teaching a client to prevent future urinary tract infections (UTIs). What factor is most important to emphasize as the potential cause? a. Poor hygiene b. Constipation c. Urinary stasis d. Congenital anomalies ANS: C Urinary stasis is the single most important host factor that influences the development of UTIs. Urine is usually sterile but at body temperature provides 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. 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, the child has restricted 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 growth and tissue healing are essential. With the child having little appetite and the fluid and salt restrictions, achieving adequate nutrition is difficult. 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 prognosis. Creatinine clearance is not correlated with prognosis. The presence of significant proteinuria is used for diagnosis. It is not predictive of prognosis. 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. 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 is dehydration 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. 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 intact, an osmotic diuresis will occur. Propranolol is a beta-blocker; it will not produce a rapid flow of urine in ARF. Calcium gluconate is administered for its protective cardiac 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. 21. What major complication is associated with a child with chronic 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. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure. 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 meals to prevent its absorption, which enables a more liberal intake of phosphorus-containing protein. Protein is limited to the recommended daily allowance for the childs age. Further restriction is thought to negatively affect growth and neurodevelopment. Vitamin D therapy 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. 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 supportive care. The 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. 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 in control. Dialysis 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. 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 they are not as stringent as those for hemodialysis. Treatments are needed more frequently but can be done at home. 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 in end-stage renal disease. It can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis. 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 can be treated at home after the initial phase with appropriate discharge instructions, including a salt restriction of no additional salt to the childs 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. 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 of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. 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. 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. 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. 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. 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 can explain it to others is the most therapeutic approach while the parents await the gender assignment of their child. Ambiguous genitalia is a serious issue for the family. Careful testing and evaluation are necessary to aid in gender assignment to avoid lifelong problems for the child. Suggesting that parents avoid family and friends until the gender is assigned is impractical and would isolate the family from their support system while awaiting test results. The parents will be concerned. Telling them not to worry without giving them specific alternative actions would not be effective. 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. 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. Surgical repair is done to (1) prevent damage 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 in undescended 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. 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, elevating edematous parts may be helpful to shift fluid to more comfortable distributions. Areas that are particularly edematous, 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. 37. What do the clinical 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. 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 at least 3 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. 39. A nurse is evaluating the effectiveness of teaching regarding care of a child with minimal change nephrotic syndrome (MCNS) that 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. 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. 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 is not usually 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. 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 should be notified of these symptoms. 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. 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. MULTIPLE RESPONSE 1. The nurse is admitting a 9-year-old child with hemolytic uremic 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. 2. The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin (Garamycin). What interventions should the nurse plan for this child with regard to this 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 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. 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 rash, urticaria, and photosensitivity. Pneumonitis and renal toxicity are not side effects of Bactrim. 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. 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 tract disorder in 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. 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 tract disorder in the infancy period are pallor, poor feeding, excessive thirst, and frequent urination. Hyperthermia is seen, not hypothermia. 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. 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 for children with severe azotemia resulting from prolonged oliguria. A low-protein, high-fat diet with encouragement of fluids would not be recommended. 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. 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. 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. 12. Parents of a child who will need hemodialysis ask the nurse, What are the advantages of a fistula over a graft or external access device for hemodialysis? What response should the nurse give? (Select all that apply.) 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 repeated venipuncture. Fewer complications and less restriction of activity are observed with the use of a fistula. Both the graft and the fistula require needle insertion at each dialysis. The fistula cannot be used immediately. 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 decreased, serum creatinine are signs of rejection. MATCHING Match the classification of urinary tract infections of inflammations to its definition. a. Persistent urinary tract infection- 3. Persistence of bacteriuria despite antibiotic treatment b. Cystitis- 5. Inflammation of the bladder c. Urethritis- 4. Inflammation of the urethra d. Pyelonephritis- 1. Inflammation of the upper urinary tract and kidneys e. Urosepsis- 2. Febrile urinary tract infection coexisting with systemic signs of bacterial illness 1. Inflammation of the upper urinary tract and kidneys-D. PYELONEPHRITIS 2. Febrile urinary tract infection coexisting with systemic signs of bacterial illness-E. UROSEPSIS 3. Persistence of bacteriuria despite antibiotic treatment- A. PERSISTANT URINARY TRACT INFECTION 4. Inflammation of the urethra- C. URETHRITIS 5. Inflammation of the bladder- B. CYSTITIS 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) detects the presence of antigens and antibodies. It is not useful for disorders of metabolism. 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. 3. The mother of a child with cognitive impairment calls the nurse because her 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 may be signs of esophageal obstruction. The child is unable to swallow saliva, which contributes to the drooling. Signs of gastrointestinal (GI) perforation include chest 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. 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 fruits, especially those with skins and seeds, other than ripe bananas, have high fiber. 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 return to normal size. Dietary 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. 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. 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. 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. 9. A child has a nasogastric (NG) tube after surgery for Hirschsprung 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. 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 and increase 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. 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 perform at this time? a. Notify the practitioner. 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. 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 exacerbate bowel problems caused by lactose intolerance. Antispasmodic drugs, antidiarrheal drugs, and simethicone are beneficial for some individuals. Proton pump inhibitors have no effect. 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. 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). 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. 16. What statement is most descriptive 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. 17. One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis (UC) is that UC is more likely to cause which clinical 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. 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. 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. 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. 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 orifice. 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. 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 that contains gluten. Also, in the early stages of celiac disease, the child may be lactose intolerant. Oatmeal contains gluten. 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 which reason? 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 intestines ability to increase its absorptive capacity. Continuous enteral feedings facilitate the adaptation. TPN is indicated until the child is able to receive all nutrition via the enteral route. Before this is accomplished, the small 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. 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 from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red. 25. A child with acute gastrointestinal 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. 26. What signs or symptoms are most commonly 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 most common in the prodromal phase are anorexia, malaise, lethargy, 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. 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 for hepatitis B is recommended for all newborns. Hepatitis A vaccine is recommended for infants starting at 12 months. No vaccine is currently available for hepatitis C. 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 route. Family members must be taught preventive measures. Rest and quiet activities are essential and adjusted to the childs 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. 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 treatment for end-stage liver disease 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 treat cirrhosis. Nutritional support is necessary for the child with cirrhosis, but 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. 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 saliva is indicative of a tracheoesophageal fistula. The child is unable to swallow the secretions, so there 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. 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 imperative that any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx. 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. 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 nursing care for a newborn with an anorectal malformation. This helps alleviate intraabdominal pressure until surgical intervention. Suctioning is not necessary for an infant with this type of anomaly. Feedings are not indicated until it is determined that the gastrointestinal tract is intact. Supine position with head elevated is indicated for infants with a tracheoesophageal fistula, not anorectal malformations. 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 will place strain on the suture line. Daily enemas are contraindicated after 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. 35. The parents of a newborn with an umbilical hernia ask about treatment options. 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 rarely become problematic. Incarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation. 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 gastric decompression. 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. 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 rates range from 27% to 75%. 38. A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse 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. 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 the postoperative period to avoid anastomotic strictures but not stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the rectum in Hirschsprung disease, just strictures. 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. 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. 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. 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 of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and rye but also in smaller 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. 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 technical complications can occur. Sepsis can occur after improper 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 not characteristics of short bowel syndrome with extended TPN. 45. A child is being admitted to the hospital with acute gastroenteritis. 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. 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. 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. 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 enemas. Such measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics should be administered, and antipyretics are not contraindicated. 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 may occur intermittently and appear as tarry stools. The stools are not clay colored, steatorrhea, or loose with undigested food. 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. 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 (up on the 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 if recommended by the health care provider; 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. 2. The nurse is preparing to admit a 3-year-old child with intussusception. What 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. 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. 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. 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. 6. The nurse is preparing to admit a 6-year-old child with irritable bowel syndrome (IBS). What clinical manifestations should the nurse expect to observe? (Select all 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. 7. The nurse is caring for a child with celiac disease. The 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. 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 absorption (steatorrhea and foul-smelling stools) and impaired nutrient absorption (malnutrition). Anemia, not polycythemia, is a manifestation, and melena stools do not occur. 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. Pallor is seen, not a flushed face, and the bowel sounds are hypoactive or absent, not hyperactive. 10. The nurse is preparing to admit a 2-month-old child with hypertrophic pyloric stenosis. What clinical manifestations should the nurse expect to observe? (Select 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. 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. 12. The nurse is preparing to admit a 5-year-old child with hepatitis 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. 13. The nurse is preparing to admit a 7-year-old child with hepatitis 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. 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. MATCHING Diagnosis of hepatitis B is confirmed by the detection of various hepatitis virus antigens, and the antibodies that are produced in response to the infection. Match the antibody or antigen to its definition. a. HBsAg- 4. Indicates ongoing infection or carrier state b. Anti-HBs-3. Indicates resolving or past infection c. HBcAg-2. Detected only in the liver d. HBeAg- 1. Indicates active infection 1. Indicates active infection-D. HBeAg 2. Detected only in the liver-C. HBcAg 3. Indicates resolving or past infection-B. ANTI-HBs 4. Indicates ongoing infection or carrier state-A. HBsAg 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 safer than steam vaporizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam loosens secretions, not dries them. Both cool-mist vaporizers and steam vaporizers may promote a more comfortable environment, but cool-mist vaporizers have decreased risk for burns and growth of organisms. 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 bacteria. Drops 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. 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. 4. It is important that a child with acute streptococcal pharyngitis be 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 hemolytic streptococcal 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 posterior pituitary. Infections such as meningitis or encephalitis, not streptococcal pharyngitis, can cause DI. Glomerulonephritis, not nephrotic syndrome, can result from acute streptococcal pharyngitis. 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 that is trickling from the operative site. Gargling is discouraged because it could irritate the operative site. Ice compresses are recommended to reduce inflammation. The child should be positioned on the side or abdomen to facilitate drainage of secretions. 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 Epstein-Barr virus is the principal cause. Usually, an increase in lymphocytes is observed. Penicillin, not ampicillin, is indicated. Ampicillin is linked with a discrete macular eruption in infectious mononucleosis. 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. 8. An 18-month-old child is seen in the clinic with otitis media (OM). Oral amoxicillin 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. 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. 10. Chronic otitis media with effusion (OME) differs from acute otitis media (AOM) 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 fullness in the ear or other nonspecific complaints. OME does not cause severe pain. This may be a sign of AOM. Vomiting, anorexia, and fever are associated with AOM. 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 a medical 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. 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. Stridor is aggravated when a child with epiglottitis is supine. Epiglottitis is caused by Haemophilus influenzae in the respiratory tract. 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. 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 and that separation 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. 15. An infant with bronchiolitis is hospitalized. The causative organism is respiratory 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 required. Caregivers must 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. 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. 17. What consideration is most important in managing tuberculosis (TB) in children? 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. 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. 19. The nurse is caring for a child with acute 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. 20. The nurse is caring for a child with carbon monoxide (CO) poisoning associated with smoke inhalation. What intervention is essential in this childs 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. 21. What diagnostic test for allergies involves the 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 is the most commonly used diagnostic test for allergy. A specific allergen is injected under the skin, and after a suitable 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 specific allergens. RAST determines the level of specific IgE antibodies. Blood examination for total IgE would not distinguish among allergens. 22. What statement is the most descriptive 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. 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. 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 occurs with acute respiratory distress or failure and maybe stridor. 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. The triggers 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. 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. 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. Most children with asthma can participate provided their asthma is under control. Inflammation is the underlying cause of the symptoms of asthma. By decreasing inflammation and reducing the symptomatic airway narrowing, health care providers can minimize exacerbations. Pharmacologic agents are used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. It is recommended that children with asthma be evaluated every 6 months. 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. 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 results from the thick intestinal secretions, which can lead to blockage and rectal prolapse. 30. What is the earliest recognizable clinical 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 include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul- smelling stools and recurrent respiratory infections are later manifestations of CF. 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. 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 when used after CPT. Oxygen is administered only in acute episodes, with caution, because of chronic carbon dioxide retention. 33. A child with cystic fibrosis is receiving recombinant human deoxyribonuclease (DNase). What statement about DNase is true? 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 the only adverse effects of DNase is voice alterations and laryngitis. DNase is given in an aerosolized form, decreases the viscosity of mucus, and is safe for children younger than 12 years. 34. The parent of a child with cystic fibrosis (CF) calls the clinic nurse to report that the child has 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 what 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. 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 given just before 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. 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. 37. A child is admitted with acute laryngotracheobronchitis (LTB). The child will most likely be treated with which? 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 cool mist. The beta-adrenergic effects cause mucosal vasoconstriction and subsequent decreased subglottic edema. The use of corticosteroids is beneficial because the anti-inflammatory effects decrease subglottic edema. Nebulizer treatments are not effective even though oxygen may be required. Antibiotics are not used because it is a viral infection. Chest physiotherapy would not be instituted. 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 health care provider. 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. 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 (orally) or PR (rectally) 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. 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 the treatment and to identify potential 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. 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. 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) recommends 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 in an infant seat would not 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. 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. 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. 45. A 3-year-old is brought to the emergency department with symptoms of stridor, fever, restlessness, and drooling. No coughing is observed. Based on these findings, the nurse should be prepared to assist with what action? 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. 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. 47. A 3-month-old infant is admitted to the pediatric unit for treatment of bronchiolitis. The 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 preferred until the acute stage 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. 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 should be 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. 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. 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 unrestricted fat (because of the impaired intestinal absorption). 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. 52. A preschool child has asthma, and a goal is to extend expiratory time and increase expiratory effectiveness. What action 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, or suppressing a cough will not increase expiratory effectiveness. 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 to be increased. Call the practitioner if the child stays in this zone. 54. A family requires home care teaching with regard to preventative 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. 55. A school-age child with cystic fibrosis takes four enzyme capsules with meals. The child is 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. 56. A term infant is delivered, and before delivery, the medical team was notified that a congenital diaphragmatic hernia (CDH) was diagnosed on ultrasonography. What should be done immediately at birth if respiratory distress is noted? 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. 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 large droplets or physical transfer of respiratory secretions containing the organism. 58. What medication is contraindicated in children post tonsillectomy and adenoidectomy? a. Codeine b. Ondansetron (Zofran) c Amoxil (amoxicillin) . d 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. 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%. 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. 3. What interventions can the nurse teach parents to do to ease respiratory efforts for a child with a mild respiratory 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 symptomatic 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. 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. 5. The clinic nurse is administering influenza vaccinations. Which children should not receive the live attenuated influenza vaccine (LAIV)? (Select all that 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 years. It is a live vaccine administered via nasal 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 with a history of Guillain-Barr Syndrome after a previous dose. A child with hemophilia A or gastroesophageal reflux disease would not be immunocompromised so they can receive the LAIV. 6. The nurse is preparing to admit a 7-year-old child with acute laryngotracheobronchitis (LTB). What clinical manifestations should the nurse expect to observe? (Select 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. 7. The nurse is preparing to admit a 3-year-old child with acute spasmodic laryngitis. What clinical features of hepatitis B should the nurse 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. 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 and extrapulmonary 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. 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 in a child 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. 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. [Show More]

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