Exam 3 Quizzes
Which immunoglobin occurs most frequently in plasma and is the major immunoglobulin synthesized during secondary response? A- IgG B- IgA C- IgM D- IgD
A IgG is the most frequent antibody in plasma and is the major immunoglobin to be synthesized during the secondary response. IgG represents about 75% of all serum antibodies. Most of the newborn's IgG is transferred via the placenta to the fetus. The infant develops passive immunity to antigens in which the mother has developed antibodies. The infant begins to manufacture IgG after about 6 months of age. IgG reaches 50% of its adult level at 1 year of age and full adult level at age 7 years. IgD is only found in about 1% of plasma. Its function is to signal for B cells to be activated. IgA protects the mucus membranes against the invasion of microbes. IgM is the first antibody to respond to infection.
An adolescent with scoliosis is refusing to wear the prescribed body brace. Which instruction is best to progress the adolescent to the treatment goals? A- "It is important to wear the brace now to improve your spinal alignment, decreasing your symptoms." B- "It is important to prevent herniation of a spinal disk, which is painful." C- "It is important to correct spinal curvature before it gets too bad, causing you problems." D- "It is important to prevent torticollis."
A It is important to have the adolescent understand the treatment and how the treatment will benefit him or her. Body bracing helps to hold the spine in alignment and prevent further curvature, decreasing the symptoms. The brace will not correct the problem. Adolescents have a hard time being compliant with the brace due to body image disturbance and peer reaction. The brace can also cause discomfort and be hot to wear. Torticollis is tightened neck muscles causing the head to tilt downward. A herniated disc is related to the disc space between the vertebrae. It has no affect on the curvature of the spine.
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant? A- Lower right B- Upper left C- Upper right D- Lower left
A With appendicitis, percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness present with palpation in the right lower quadrant, is referred to as the McBurney point, an area of tenderness 1.5 to 2 in. (3.8 to 5 cm) in from the right anterior superior iliac spine along a line extending to the umbilicus.
The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical manifestation would likely have been noted in the child with this diagnosis? A- Jaundiced skin B- Tea-colored urine C- Loose, dark stools D- Strawberry-red tongue
B The presenting symptom in acute glomerulonephritis is grossly bloody urine. The caregiver may describe the urine as tea or cola colored. Periorbital edema may accompany or precede hematuria. Loose stools are seen in diarrhea. A strawberry-colored tongue is a symptom seen in the child with Kawasaki disease. Jaundiced skin is noted in hepatitis.
A school nurse is teaching a group of parents about signs and symptoms of cancer in children. Which symptom is an early sign of a brain tumor? A- nystagmus, ataxia, and seizures B- headache, epistaxis, and dizziness C- headache, vision changes, and vomiting D-projectile vomiting, lethargy, and coma
C Children with any form of brain tumor develop symptoms of increased intracranial pressure: headache, vision changes, vomiting, an enlarging head circumference, or papilledema. Lethargy, projectile vomiting, and coma are late signs. Epistaxis is not usually related to a brain tumor. A growing tumor produces specific localized signs, such as nystagmus (constant horizontal movement of the eye) or visual field defects. As tumor growth continues, symptoms of ataxia, personality change (e.g., emotional lability, irritability), and seizures may occur. These would be later symptoms.
A nurse is caring for a 17-year-old female client with bulimia. Which complication of this disease may the nurse see in this child? A- Hernia B- Menstrual problems C- Partial paralysis D- Severe acne
B Paralysis, hernia, and acne are not distinguishing features of bulimia. Bulimia is an eating disorder that has assessment findings of menstrual problems, esophagitis, cardiac arrhythmias, and fluid and electrolyte imbalance.
The nurse is caring for a 10-year-old girl with an anxiety disorder. During a physical examination, which physical finding would the nurse expect? A- Dilated eyes B- Patches of hair loss C- Watery eyes D- Absence of nasal hair
B Patches of hair loss that occur with repetitive hair twisting or pulling are associated with anxiety. Watery, dilated eyes and the absence of nasal hair are often signs of substance abuse.
The nurse is assessing a school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis? A- Slightly yellow sclera B- Enlarged mandibular growth C- Increased growth of long bones D- Depigmented areas on the abdomen
A In sickle-cell anemia, eye scleras become icteric or yellowed from the release of bilirubin from the destruction of the sickled cells. Mandibular and long bone growth and depigmentation are not manifestations of this health problem.
The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myelogenous leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately? A- Temperature of 101° F (38.3° C) or greater B- Earache, stiff neck, or sore throat C- Blisters, ulcers, or a rash appear D- Difficulty or pain when swallowing
A The parents should seek medical care immediately if the child has a temperature of 101°F (38.3° C) or greater. This is because many chemotherapeutic drugs cause bone marrow suppression; the parents must be directed to take action at the first sign of infection in order to prevent overwhelming sepsis. The appearance of earache, stiff neck, sore throat, blisters, ulcers, or rashes, or difficulty or pain when swallowing are reasons to seek medical care, but are not as grave as the risk of infection.
The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. Of the following foods, which would most likely be appropriate in the child's diet? A- Potatoes B- Bananas C- Oatmeal D- Toast
B The young child should be started on a starch-free, low-fat diet. Bananas contain invert sugar and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded.
The nurse is caring for a newborn with facial nerve palsy from birth trauma. The mother is very upset and concerned about the child's prognosis. Which response by the nurse would be most appropriate? A- "This is the most common facial nerve palsy." B- "Have you seen any signs of improvement?" C- "In most cases treatment is not necessary, only observation." D- "Was this from pressure resulting from forceps?"
C The nurse should reassure the mother by reminding her that in most cases treatment is not necessary, only observation. Asking about signs of improvement might alarm the mother because in some cases it can take many months for the palsy to resolve. Asking whether this was a result of pressure from forceps does not address the mother's concerns about the child's prognosis. The mother may not understand or know why the condition occurred. Telling the mother that this is the most common facial nerve palsy does not address the mother's concerns about the child's prognosis
A 25lb child was ordered for Tylenol 115mg PO every 4 hour hours as needed for pain. Is this a safe dose (standard is 10-15/kg/dose)? A- Yes B- No
A
Through which mechanism is Duchenne muscular dystrophy acquired? A- Heredity B- Autoimmune factors C- Virus D- Environmental toxins
A Muscular dystrophy is hereditary and acquired through a recessive sex-linked trait. Therefore, it isn't caused by viral, autoimmune, or environmental factors.
A mother brings her 4 day old infant to the clinic w/ vomiting and poor feeding. The newborn was healthy at birth. The nurse should suspect: A- sturge-Weber syndrome B- an inborn error of metabolism C- trisomy 18 D- turner syndrome
B
The nurse is caring for a 14 year old boy with type 1 DM. He takes NPH insulin every morning at 7:30 am. Which assessment data will the nurse use to evaluate the therapeutic effectiveness of the medication? A- presence of s/s of hypoglycemia or hyperglycemia during the morning physical assessment B- blood glucose level at 1630 C- appetite and food intake at lunch D- blood glucose level before breakfast
B
The nurse is caring for a child w/ Down syndrome. What should the nurse's focus be? A- teaching hygiene skills to the child in order to increase self-esteem B- screening for anomalies and teaching about prevention of respiratory infection C- finding opportunities to increase socialization for the child and family D- expecting walking at age 1 year and toilet training completion at age 2 years
B
Which couple will the nurse highlight for the primary health care provider as being at highest risk for having a child with a trisomy 21 disorder? A- A teenage couple with limited prenatal care B- A couple in their late 40s C- A couple with a history of drug use D- A couple of African descent
B Race and a history of drug use are not related to increased trisomy disorders. Although a lack of prenatal care can contribute, advanced maternal age (older than age 35) introduces the highest risk for a trisomy disorder.
The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of the greatest concern? A- Elevated temperature B- Elevated blood pressure C- Hypotension D- Reduced body temperature
B Renal complications may result from lupus. This may be accompanied by hypertension making monitoring of blood pressure of the highest importance
A 25lb child was ordered for Tylenol 115mg PO every 4 hour hours as needed for pain. How many mls would you administer (Tylenol 160mg/5ml)? Round the decimal to the nearest tenth. A- 3.4 B- 3.8 C- 3.6 D- 3.7
C
A 55lb child requires a dose of Benadryl and he will only take the chewable tablets. The doctor orders 25mg every 6 hours as needed for hives. How many tablets will the child receive per dose? (Benadryl chewable tablet - 12.5mg) A- 1/2 tablet B- 1 tablet C- 2 tablets D- 1 and 1/2 tablets
C
The nurse is collecting data for a child diagnosed with acute glomerulonephritis. What would the nurse likely find in this child's history? A- The child had a congenital heart defect B- The child has a sibling with the same diagnosis C- The child recently had an ear infection D- The child is being treated for asthma.
C In the child with acute glomerulonephritis, presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection, such as strep throat, otitis media, tonsillitis, or impetigo. There is not a family history of the disorder, a history of congenital concerns or defects, nor asthma in children with acute glomerulonephritis.
The condition in which one or both of the testes does not descend in the male infant is referred to as: A- enuresis B- hydrocele C- orchiopexy D- cryptorchidism.
D When one or both of the testes do not descend, the condition is called cryptorchidism. An orchiopexy is the surgical procedure to pull the testes down into the scrotal sac. If the undescended testicle is left untreated it can can sterility in the adult male. A hydrocele is fluid in the scrotal sac. It generally resolves without surgery. Enuresis is nighttime bed wetting.
A child born w/ a single transverse palmar crease, a short neck with excessive skin at the nape, a depressed nasal bridge, and cardiac defects is most likely to have which autosomal abnormality? A- trisomy 21 B- trisomy 18 C- trisomy 14 D- trisomy 13
A
Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? A- Risk for suffocation B- Risk for imbalanced body temperature C- Risk for falls D- Noncompliance
A Death from drowning occurs from suffocation. Nearly half of all drowning victims are children under the age of 5. Most drowning deaths in young children occur because of inadequate supervision of a bathtub or pool.
The nurse is caring for a 2-month-old in a pediatric clinic. The mom states she is going on vacation in Florida in a month and she is concerned about sunburn. She asks if it is okay to use a sunscreen lotion made for children. What is the correct nursing response? A- "Put plenty of children's sunscreen on the infant at least 15 minutes before going outdoors, then reapply every three to four hours." B- "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun." C- "You should not take your infant to Florida." D- "It is okay to use a children's sunscreen as long as you avoid the face."
B Do not use sunscreens on children younger than 6 months of age. Instead, use hats, bonnets, and light-colored clothes to shield the skin, and keep the infant away from direct exposure to the sun. Telling the mother not to take the infant to Florida is inappropriate.
A nurse is providing care to a toddler with nephroblastoma and is being evaluated. Which nursing action would be most important? A- Preventing weight-bearing activities B- Placing a "no abdominal palpation" sign above the child's bed C- Ensuring that the child be allowed nothing by mouth D- Preparing the child for chemotherapy
B Nephroblastoma (Wilms' tumor) metastasizes rapidly, so it is important that the child's abdomen not be palpated any more than necessary for diagnosis, because handling appears to aid metastasis. There is no need to restrict the child's visitors. Ensuring nothing by mouth would be appropriate prior to surgery. Preventing weight-bearing activities would be appropriate for a child with Ewing's sarcoma
A young mother brings her new baby dx w/ congenital hypothyroidism, to the clinic, so she can learn how to administer levothyroxine. The nurse should include which of the following instructions? A- crush the med and place it in a formula to disguise the taste B- administer the med every other day C- use an oral dispenser syringe or nipple to give the crushed med mix w/ a small amount of formula D- tell the mother tha the med will not be needed after the age of 7
C
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? A- Evaluate gastric pH B- Determine esophageal contractility C- Detect Helicobacter pylori D- Confirm pancreatitis
C Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness.
When monitoring the blood glucose level of a 12 year old child with type 2 DM, your reading is 50mg/dL. Which is the most appropriate action? A- encourage the child to get out of bed and increase activity B- take child's vital signs C- ask the child about frequent urine output D- give the child 4 oz of orange juice
D
You are counseling a couple, one of whom is affected by neurofibromatosis, an autosomal dominant disorder. They want to know the risk of transmitting the disorder. The nurse should tell them that each offspring has a: A- one in four (25%) chance of getting the disease B- one in eight (12.5%) chance of getting the disease C- one in one (100%) chance of getting the disease D- one in two (50%) chance of getting the disease
D
What is the maintenance fluid rate for a 22 kg child A- 65 B- 1500 C- 1540 D- 64.2
D Maintenance Fluid: 10 kg x 100 = 100 10 kg x 50 = 500 2 kg x 20 = 40 1000 + 500 + 40 = 1540 Total volume = 1540 mL over 24 hours 1540 divided by 24 = (64.2 mL/hr)
Which goal of therapy would be appropriate for a nurse to establish with a client's family and a client who has a diagnosis of enuresis? A- The client wets only when involved in an activity B- The child wakes up once during the night for a glass of water C- The parent takes the client to the bathroom at night D- The client remains continent throughout the night.
D The goal of therapy is for the client to be continent of urine throughout the night. The nurse should encourage the child to awaken and void and not have any fluids before bedtime. During an activity, the child should be encouraged to void before and after the activity to prevent incontinence.
A nurse is conducting a physical examination on an 11-year-old boy with Legg-Calvé-Perthes disease. Which assessment finding would be expected? A- Lordosis B- Loss of strength in ankle dorsiflexion C- Kyphosis D- Trendelenburg gait
D The nurse would expect to note a Trendelenburg gait due to pain. Lordosis is an excessive curvature of the spine and is not associated with Legg-Calvé-Perthes disease. Kyphosis is an excessive curvature of the spine and is not associated with Legg-Calvé-Perthes disease. Loss of strength in ankle dorsiflexion is associated with some neuromuscular disorders but not this condition.
Doctor's order: Augmenting oral suspension 280 mg P.O. three times a day. Available as 125mg/5mL. How many mLs will the nurse administer for one dose? A- 12 B- 11.5 C- 11 D- 11.2 mls
D mL/dose = 5 mL/125 mg X 280 mg/dose = 11.2 mL/dose or Desired over what you have, times quantity. D/H x Q 280/125 x 5 = 11.2
A young child has just been admitted to the emergency department with a burn that encompasses the dermis and the underlying dermis. From which type of burn does this child suffer? A- Second-degree or partial-thickness burn B- Fourth-degree or fat-layer burn C- First-degree or superficial burn D- Third-degree or full-thickness burn
A A burn that encompasses the dermis and the underlying dermis is a second-degree burn. A first-degree burn would only involve the epidermis, and a third-degree burn would involve nerve endings as well as destruction of the epidermis and dermis. A fourth-degree burn would extend even deeper into the fat layer.
A nurse is providing care to a child diagnosed with cerebral palsy who is experiencing painful muscle spasms. The health care provider has prescribed baclofen 40 mg/day PO in three divided doses. How many milligrams should the nurse administer in each dose? Record your answer using one decimal place. A- 13.3 B- 3 C- 13.333333333 D- 12
A The nurse will divide the number of doses per day into the total amount prescribed for each day. 40 mg ÷ 3 doses = 13.3 mg/dose
The nurse is caring for a child w/ Turner syndrome admitted to the unit for tx of a kidney infection. What characteristics associated w/ this syndrome may the nurse expect to find upon assessment? A- microcephaly, polydactyly B- low-set ears, cleft lip C- short stature, webbed neck D- gynecomastia, taller than average
C
The nurse is caring for a 10-year-old diagnosed with depression. The child weighs 72 lb. The medication order reads: fluoxetine 10mg PO daily. The child refuses to swallow pills. Fluoxetine is supplied as 20 mg/5ml. How many milliliters will the nurse administer? Round to the nearest tenth. A- 2.4 ml B- 3 ml C- 2.6 ml D- 2.5 ml
D Order: fluoxetine 10 mg PO daily Supplied: fluoxetine 20 mg/5 ml 10 mg/x = 20 mg/5 ml Cross multiply. 20x = 10 x 5 ml 20x = 50 ml Divide both sides by 20 20x/20 = 50 ml/20 x = 2.5 ml My answer: D/H x Q (desired divided by what you have, times the quantity) 10 divided by 20, times 5 = 2.5 ml
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the expect to hear described? A- Vomiting about 2 hours after feeding B- Vomiting immediately after feeding C- Refusal to eat D- Chronic diarrhea
B With pyeloric stenosis the circular muscle pyloris is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eatling. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.
A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread? Select all that apply. A- Sharing the same bathroom B- Sharing contaminated needles C- Through breastfeeding D- Exposure to blood and body fluids through sexual contact E- Transfusion of contaminated blood F- Perinatally from mother to fetus
B, C, D, E, F HIV is spread by exposure to blood and other body fluids through sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood, perinatally from mother to fetus, and through breastfeeding. It can not be contracted through using the same bathroom. It must be direct contact.
During a well-child examination which of the following comments made by the pt would indicate the possibility of a growth hormone deficiency? A- "i have to buy my child new clothes every 2 to 3 months" B- "i have to buy my child much larger shirts than pants but then the sleeves are too long" C- "my child wears out his clothes before he outgrows them" D- "i can hand down my child's clothes to his younger brother"
C
The nurse working in a women's health clinic determines that genetic counseling may be appropriate for a women: A- who just had her first miscarriage at 10 weeks B- who is 30 years old and planning to conceive C- whose hx reveals a close relative with fragile X syndrome D- who is 18 weeks pregnant and whose triple screen came back normal
C
The nurse is caring for an infant with supraventricular tachycardia who is symptomatic and has an IV line in place. The infant weighs 16 ½ lb. The medication order reads: adenosine 0.01 mg/kg IV STAT followed by rapid flush. Adenosine is supplied as 6 mg/2 mL. How many milliliters will the nurse administer? Round to the nearest hundredth. A- 0.025 B- 0.02 C- 0.024 D- 0.03
D Order: adenosine 0.01 mg/kg IV STAT Supplied: adenosine 6 mg/2 ml 16.5 pounds divided by 2.2 = 7.5 kg 7.5 times 0.01 = 0.075 0.075 mg/x = 6 mg/2 ml Cross multiply 6x = 0.075 times 2 ml 6x = 0.15 mL Divide both sides by 6 6x/6 = 0.15 ml/6 x = 0.025 ml Round to 0.03 ml My version: D/H x Q (Desired divided by what you have, times the quantity) I convert the pounds to kg. 16.5 / 2.2 = 7.5 kg Take the kg and times it by the dose 7.5kg x 0.01 = 0.075 mg you then take the desired dose (0.075 mg) and divide it by the dose you have (6 mg) 0.075 mg/ 6 mg = 0.0125 then you take that dose times your quantity 0.0125 x 2 = 0.025ml rounded to 0.03
Which sign or symptom suggests that a 5-year-old boy who does not maintain eye contact or speak may have autism spectrum disorder (ASD)? A- The child has a long face and prominent jaw. B- The child is highly active and inattentive. C- The child has a slight decrease in head circumference. D- The child constantly opens and closes his hands.
D Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for ASD. A high level of activity and inattentiveness are typical symptoms of intellectual disability. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome.
The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first? A- Discontinue the infusion. B- Check the physician's orders for an antiemetic. C- Contact the physician. D- Take the client's vital signs.
A Clients receiving intravenous immunoglobulin are at risk for anaphylaxis. Vomiting can signal an allergic response. The first action would be to stop the infusion. The remaining activities are appropriate for inclusion in the plan of care but are not of the highest priority.
The nurse is assessing a child who was brought into the clinic. The nurse notes honey-colored crusting on the toddler's face, as seen in the figure. The nurse recognizes this to be what type of infection? A- Impetigo B- Scabies C- Folliculitis D- Atopic dermatitis
A Impetigo is a readily recognizable skin rash that is characterized with honey-colored crusting. Nonbullous impetigo generally follows some type of skin trauma or may arise as a secondary bacterial infection of another skin disorder, such as atopic dermatitis. Bullous impetigo demonstrates a sporadic occurrence pattern and develops on intact skin, resulting from toxin production by S. aureus.
A child has fallen off of a swing at the playground and her father states that she became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next? A- Assess level of consciousness B- Remove the child's clothing. C- Provide pain management. D- Obtain a full set of vital signs.
A Once the ABCs are completed, the nurse's next step is to assess the child's level of consciousness or disability. This would be followed by removing the child's clothing and diaper (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs and facilitating family, and giving comfort.
The nurse measures the client's blook glucose level prior to breakfast. The measurement obtained is 130 mg/dl. The orders read to administer 2 units of Humalog insulin for a blood glucose of 100 to 150 mg/dl. How soon should the nurse ensure that the client eats their breakfast after receiving their insulin? A- 1 hour B- 5 min C- 15-30 D- 2 hours
C Humalog is a rapid-acting insulin. The onset of Humalog insulin is within 15 minutes and the peak level is achieved within 30 to 90 minutes; therefore, the client should eat within 15 to 30 minutes to avoid a hypoglycemic reaction.
A nurse is teaching an adolescent with type 1 diabetes about the disease. Which instruction by the nurse about how to prevent hypoglycemia would be most appropriate for the adolescent? A- "Check your blood glucose level before exercising, and eat a protein snack if the level is elevated." B- "Limit participation in planned exercise activities that involve competition." C- "Carry crackers or fruit to eat before or during periods of increased activity." D- "Increase the insulin dosage before planned or unplanned strenuous exercise."
C Hypoglycemia can usually be prevented if an adolescent with diabetes eats more food before or during exercise. Because exercise with adolescents isn't commonly planned, carrying additional carbohydrate foods is a good preventive measure.
The nurse is discussing nutritional requirements to the parents of a child diagnosed with phenylketonuria (PKU). Which food item would be appropriate to recommend? A- Fat-free milk B- Eggs whites C- Orange slices D- Lean chicken
C PKU is an inborn error of metabolism that requires foods low in phenylalanine, aspartame, and protein. Orange slices or fruits and vegetables are appropriate recommendations. Eggs, dairy, meat, and poultry products should be avoided.
During an assessment of an adolescent child, the nurse notes that the child has a protuberant tongue, fatigued appearance, poor muscle tone and exophthalmos. What medical diagnosis would the nurse expect the child to have? A- Diabetes mellitus B- SIADH C- Graves disease D- Cushing disease
C Symptoms of Graves disease include an increased rate of growth; weight loss despite an excellent appetite; hyperactivity; warm, moist skin; tachycardia; fine tremors; an enlarged thyroid gland or goiter; and ophthalmic changes including exophthalmos. These are not symptoms of Cushing disease, diabetes mellitus or SIADH.
A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention? A- Provide sedation as prescribed. B- Have the client sit up straight in a chair. C- Administer 100% oxygen by mask. D- Check the client's capillary refill time.
C Management of the near-drowning victim focuses on assessing the client's airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the adolescent assume the most comfortable position for him or her. Checking capillary refill time helps determine ineffective tissue perfusion, but it does not provide an intervention for the labored breathing. Providing sedation is an intervention for pain. Pain is assessed after the ABCs and neuro assessments are completed.
Prior to discharging an infant with congenital hypothyroidism to home with the parents, what should the nurse emphasize regarding the care that this child will need going forward? A- Administration of vitamin C until after growth is complete B- Vitamin K administration until school age C- Administration of levothyroxine indefinitely D- An increased intake of calcium beginning immediately
C The treatment for hypothyroidism is oral administration of synthetic thyroid hormone or sodium levothyroxine. A small dose is given at first, and then the dose is gradually increased to therapeutic levels. The child needs to continue taking the synthetic thyroid hormone indefinitely to supplement that which the thyroid does not make. Vitamin K is not needed. Supplemental vitamin D, and not calcium, may be given to prevent the development of rickets when rapid bone growth begins. Supplemental vitamin C is not indicated for this disorder.
The nurse is caring for a child with Down Syndrome. The child weighs 26 lb. The physician orders intravenous maintenance fluids. What would be the expected maintenance IV fluid rate? (round to nearest ml) A- 45.5 B- 45 C- 46.5 D- 46
D Calculations: 26 pounds divided by 2.2= 12kg (refer to Table 13.4 in Chapter 13). 100 mL/kg of weight for the first 10 kg + 50 mL/kg for the next 10 kg = amount of mL for 24 hours. Then divide by 24 to get hourly rate. (10 x 100=1000) plus (2 x 50)=100 Total =1100 in 24 hours. 1100/24= 45.8 or 46 mL per hour
When teaching about Turner's syndrome, what should the nurse include? A- Long-term effects of decreased intellectual ability B- Use of hormone therapy to prevent infertility C- Timing and use of growth hormone D- Treatment for gynecomastia
C Growth hormone is used once the child has fallen below the 5th percentile on the growth charts. Hormone therapy will be used to intiate puberty, not to prevent infertility. Gynecomastia is a common finding in children suffering from Klinefelter, not Turner's, syndrome.
The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. What follow-up will the nurse expect? A- referred for counseling B- put on a high-calorie, high-protein diet C- started on methylphenidate D- administered antidiarrheal medications
A Encopresis is the repeated involuntary passage of feces of normal or near-normal stool in places not appropriate for that purpose. If no organic causes (e.g., worms, megacolon) exist, encopresis indicates a serious emotional problem and a need for counseling for the child and the family caregivers. Medications such as methylphenidate are used for hyperactivity. The diet needs to be high fiber. Antidiarrheals are contraindicated because they can cause more constipation. Lubricant laxatives should be used.
Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura? A- Ineffective tissue perfusion related to poor platelet formation B- Ineffective breathing pattern related to decreased white blood count C- Risk for altered urinary elimination related to kidney impairment D- Risk for infection related to abnormal immune system
A Idiopathic thrombocytopenic purpura (ITP) results from an immune response following a viral infection that produces antiplatelet antibodies. These antibodies destroy the platelets which cause petechiae, purpura and excessive bleeding. ITP does not affect the kidneys. Breathing difficulties would not occur with decreased whit blood cells. It occurs when there is decreased red blood cells. The child who develops ITP has no different immune system than othe children who are healthy.
A child's parent calls the clinic nurse and states, "My child just drank an unknown amount of a cleaning solution. What should I do?" Which statement by the nurse is best? A- "You need to hang up with me and call the poison control center now." B- "You need to give your child ipecac syrup to induce vomiting." C- "Monitor your child's breathing and heart rate closely for the next 24 hours." D- "Immediately take your child to your local emergency facility."
A The nurse would tell the parent to call a poison control center to receive information of how to best treat the child. A poison control center will provide the most accurate information on the next steps for the client.The nurse would not recommend ipecac syrup, which induces vomiting. Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The child can be brought to the local emergency facility; however, calling a poison control center is best. Health care professionals should be the ones to monitor the child, not the parents or caregivers in this situation.
Why will it be necessary for the nurse to be very supportive of parents' attempts to feed the infant with recently repaired myelomeningocele? A- The infant will have a poor sucking reflex. B- Assuming the usual feeding position will be difficult. C- Nausea and vomiting often follow repair of the cystic mass. D- Pain will interfere with the feeding process.
B Because the repaired area will need to be protected, having to use an alternate feeding position is likely. The infant may need to be fed prone with the head turned to the side and may not be able to be held. Being able to provide food for the infant is central to parenting the child. Difficulty nurturing a child can be very stressful. Little pain will be experienced and should easily be controlled owing to loss of sensation in the area. The sucking reflex should not be affected by the myelomeningocele or its repair. Nausea and vomiting are unlikely after recovery from the anesthetic.
A 4-year-old child is recently diagnosed with Wilms tumor. The health care provider suggests that the child's siblings have genetic testing performed. What is the best response by the nurse when explaining this to the parents? A- "Your child has a benign tumor. The testing is not necessary, and I would suggest that you don't put your children through it." B- "The tumor is a collection of fat cells in the body that just collect in that one spot. The testing will see if the other children will develop that as well." C- "Wilms tumor is associated with a genetic link to chromosome 11; with early detection and treatment there are better outcomes." D- "The health care provider just wants to make sure there are not any other diseases in the family genes."
C Genetic testing for siblings of clients with Wilms tumor is suggested for early detection and treatment if necessary.