Pediatric Nursing - NCLEX Cardiac

Nursing care of the child with Kawasaki disease is challenging because of: a. the child's irritability. b. predictable disease course. c. complex antibiotic therapy. d. the child's ongoing requests for food.

ANS: A Patient irritability is a hallmark of Kawasaki disease and the most challenging problem. A quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should be offered to prevent dehydration.

Which of the following defects results in obstruction to blood flow? a. Aortic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

ANS: A Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect results in increased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.

In which of the following conditions are all the formed elements of the blood simultaneously depressed? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia

ANS: A Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by abnormal sickled hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin chains. Iron deficiency anemia results in a decreased amount of circulating red cells.

Which of the following is most descriptive of the spiritual development of the older adolescent? a. Beliefs become more abstract. b. Rituals and practices become increasingly important. c. Strict observance of religious customs is common. d. Emphasis is placed on external manifestations, such as whether a person goes to church.

ANS: A Because of their abstract thinking abilities, adolescents are able to interpret analogies and symbols. Rituals, practices, and strict observance of religious customs become less important as the adolescent questions values and ideals of families. Adolescents question external manifestations when not supported by adherence to supportive behaviors.

Which of the following explains why iron deficiency anemia is common during infancy? a. Cow's milk is a poor source of iron. b. Iron cannot be stored during fetal development. c. Fetal iron stores are depleted by 1 month of age. d. Dietary iron cannot be started until 12 months of age.

ANS: A Children between the ages of 12 and 36 months are at risk for anemia, since cow's milk is a major component of their diet and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by ages 5 to 6 months. Dietary iron can be introduced by breast-feeding, iron-fortified formula, and cereals during the first 12 months of life.

Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4o C (101.1° F). The nurse should do which of the following? a. Report findings to practitioner. b. Apply a hypothermia blanket. c. Keep child warm with blankets. d. Record temperature on assessment flow sheet.

ANS: A In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues after this period, it is most likely a sign of an infection, and immediate investigation is indicated. Hypothermia blanket is not indicated for this level of temperature. Blankets should be removed from the child to keep the temperature from increasing. The temperature should be recorded, but the practitioner must be notified for evaluation.

Which of the following structural defects constitute tetralogy of Fallot? a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

ANS: A Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.

A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The child's care should include which of the following? a. Hydration, pain management b. Oxygenation, factor VIII replacement c. Electrolyte replacement, administration of heparin d. Correction of alkalosis and reduction of energy expenditure

ANS: A The management of crises includes adequate hydration, pain management, minimization of energy expenditures, electrolyte replacement, and blood component therapy if indicated. Factor VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels. Also, prolonged oxygen can reduce bone marrow activity. Heparin is not indicated in the treatment of vasoocclusive sickle cell crisis. Electrolyte replacement should accompany hydration. The acidosis will be corrected as the crisis is treated. Energy expenditure should be minimized to improve oxygen utilization. Acidosis, not alkalosis, results from hypoxia, which also promotes sickling.

The primary nursing intervention to prevent bacterial endocarditis is which of the following? a. Counsel parents of high-risk children. b. Institute measures to prevent dental procedures. c. Encourage restricted mobility in susceptible children. d. Observe children for complications, such as embolism and heart failure.

ANS: A The objective of nursing care is to counsel the parents of high-risk children about the need for both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior.

A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38o C (100.4o F), and now her muscles and joints ache. Based on this information you advise the mother to: a. immediately bring the child to clinic for evaluation. b. come to the clinic next week on a scheduled appointment. c. treat the symptoms with acetaminophen and fluids, since it is most likely a viral illness. d. recognize that the child is trying to manipulate the parent by complaining of vague symptoms.

ANS: A These are the insidious symptoms of bacterial endocarditis. Since the child is in a high-risk group for this disorder (VSD repair), immediate evaluation and treatment are indicated to prevent cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated in approximately 80% of the cases. The child's complaints should not be dismissed. The low-grade fever is not a symptom that the child can fabricate.

The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. The nurse should know that: a. SCA is not inherited. b. all siblings will have SCA. c. each sibling has a 25% chance of having SCA. d. there is a 50% chance of siblings having SCA.

ANS: C SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, each child born to these parents has a 25% chance of having the disorder, a 25% chance of having neither SCA nor the trait, and a 50% chance of being heterozygous for SCA (sickle cell trait). SCA is an inherited hemoglobinopathy.

An infant age 4 months comes to the clinic for a well-infant check-up. Immunizations she should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine). She is recovering from a cold but is otherwise healthy and afebrile. Her older sister has cancer and is receiving chemotherapy. Nursing considerations include which of the following? a. DTaP and IPV can be safely given. b. DTaP and IPV are contraindicated because she has a cold. c. IPV is contraindicated because her sister is immunocompromised. d. DTaP and IPV are contraindicated because her sister is immunocompromised.

ANS: A These immunizations can be given safely. Serious illness is a contraindication. A mild illness with or without fever is not a contraindication. These are not live vaccines so they do not pose a risk to her sister.

According to Erikson, the psychosocial task of adolescence is developing which of the following? a. Identity b. Intimacy c. Initiative d. Independence

ANS: A Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Independence is not one of Erikson's developmental stages.

Which of the following statements is correct about young children who report sexual abuse? a. They may exhibit various behavioral manifestations. b. In more than half the cases the child has fabricated the story. c. Their stories should not be believed unless other evidence is apparent. d. They should be able to retell the story the same way to another person.

ANS: A Victims of sexual abuse have no typical profile. The child may exhibit various behavioral manifestations, none of which is diagnostic for sexual abuse. When children report potentially sexually abusive experiences, their reports need to be taken seriously. Other children in the household also need to be evaluated. In children who are sexually abused, it is often difficult to identify other evidence. In one study, approximately 96% of children who were sexually abused had normal genital and anal findings. The ability to retell the story is partly dependent on the child's cognitive level. Children who repeatedly tell identical stories may have been coached.

The single parent of a child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which of the following is the most appropriate nursing intervention? a. Describe the role of varicella-zoster immune globulin to treat chickenpox. b. Discuss the risks and benefits of acyclovir to treat chickenpox. c. Explain that no medication will shorten the course of the illness. d. Reassure the parent that it is not necessary to stay home with the child.

ANS: B Acyclovir is effective in reducing the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. Varicella-zoster immune globulin is given only to high-risk children. Acyclovir lessens the severity of chickenpox. It is important for the parent to stay with the child to monitor fever.

Which of the following aspects of cognition develops during adolescence? a. Ability to see things from the point of view of another b. Capability of using a future time perspective c. Capability of placing things in a sensible and logical order d. Progress from making judgments based on what they see to making judgments based on what they reason

ANS: B Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years) children exhibit thought processes that enable them to see things from the point of view of another, place things in a sensible and logical order, and progress from making judgments based on what they see to making judgments based on what they reason.

An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in the following manner: a. give half of the solution, and then repeat the other half in 1 hour. b. mix with a flavorful beverage in an opaque container with a straw. c. serve in a clear plastic cup so the child can see how much has been drunk. d. administer through a nasogastric tube, since the child will not drink it because of the taste.

ANS: B Although the activated charcoal can be mixed with a flavorful sugar-free beverage, it will be black and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being distasteful. The ability to see the charcoal solution may affect the child's desire to drink the solution. The child should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be used only in children who cannot be cooperative or those without a gag reflex.

A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in: a. cyanosis. b. congestive heart failure. c. decreased pulmonary blood flow. d. bounding pulses in upper extremities.

ANS: B As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for congestive heart failure. Cyanosis usually occurs in defects with decreased pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the aorta.

The nurse should recognize that congestive heart failure (CHF) is which of the following? a. Disease related to cardiac defects b. Consequence of an underlying cardiac defect c. Inherited disorder associated with a variety of defects d. Result of diminished workload imposed on an abnormal myocardium

ANS: B CHF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. CHF is not a disease but rather a result of the inability of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.

Which of the following is the most common form of child maltreatment? a. Sexual abuse b. Child neglect c. Physical abuse d. Emotional abuse

ANS: B Child neglect, which is characterized by the failure to provide for the child's basic needs, is the most common form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common as neglect.

Iron overload is a side effect of chronic transfusion therapy. Treatment to minimize this complication includes: a. magnetic therapy. b. infusion of deferoxamine. c. hemoglobin electrophoresis. d. washing red blood cells (RBCs) to reduce iron.

ANS: B Deferoxamine infusions in combination with vitamin C allow the iron to remain in a more chelatable form. The iron can then be excreted more easily. Use of magnets does not remove additional iron from the body. Hemoglobin electrophoresis is used to confirm the diagnosis of hemoglobinopathies; it does not affect iron overload. Washed RBCs remove white blood cells and other proteins from the unit of blood; they do not affect the iron concentration.

The regulation of red blood cell (RBC) production is thought to be controlled by: a. hemoglobin. b. tissue hypoxia. c. reticulocyte count. d. number of RBCs.

ANS: B Hemoglobin does not directly control RBC production. If there is insufficient hemoglobin to adequately oxygenate the tissue, then erythropoietin may be released. When tissue hypoxia occurs, the kidneys release erythropoietin into the bloodstream. This stimulates the marrow to produce new RBCs. Reticulocytes are immature RBCs. The "retic" count can be used to monitor hematopoiesis. The number of RBCs does not directly control production. In congenital cardiac disorders with mixed blood flow or decreased pulmonary blood flow, RBC production continues secondary to tissue hypoxia.

Which of the following is a clinical manifestation of acetaminophen poisoning? a. Hyperpyrexia b. Hepatic involvement c. Severe burning pain in stomach d. Drooling and inability to clear secretions

ANS: B Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach and does not pose an airway threat.

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. Which of the following is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure.

ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.

John is a 6-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be which of the following? a. Directed at his parents because he is too young to understand b. Adapted to his level of development so that he can understand c. Done several days before the procedure so he will be prepared d. Provide details about the actual procedures so he will know what to expect

ANS: B Preoperative teaching should always be directed to the child's stage of development. The caregivers also benefit from these explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age-group will not understand in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization.

A method for conducting a health-screening interview with adolescents is "SAFE TIMES." The nurse working with adolescents should know that "SAFE" is an acronym for: a. social roles, apathy/anger, frustration, emotional growth. b. sexuality, affect/abuse, family, examination. c. safety issues, appropriate/inappropriate behavior, firearms, employment. d. security, acceptance/nonacceptance by peers, friends, education.

ANS: B SAFE TIMES is a method for conducting health-screening interviews with adolescents as a way to ensure that all topics are covered; it is best used in reverse order. SAFE is an acronym for Sexuality, Affect and Abuse, Family, and Examination; TIMES is the acronym for Timing of development, Immunization, Minerals, Education and Employment, and Safety.

A significant secondary prevention nursing activity for lead poisoning is: a. chelation therapy. b. screening children for blood lead levels. c. removing lead-based paint from older homes. d. questioning parents about ethnic remedies containing lead.

ANS: B Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part of the assessment to determine the potential source of lead.

Which of the following is a condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia

ANS: B Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron deficiency anemia affects red cell size and depth of color but does not involve abnormal hemoglobin.

Pertussis vaccination should begin at which age? a. Birth b. 2 months c. 6 months d. 12 months

ANS: B The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. The infant is highly susceptible to pertussis, which can be a life-threatening illness in this age-group.

Which of the following should the nurse consider when preparing a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let child hear the sounds of a cardiac monitor, including alarms. c. Explain that an endotracheal tube will not be needed if the surgery goes well. d. Discussion of postoperative discomfort and interventions is not necessary before the procedure.

ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The family and child should make the decision about a tour of the unit if it is an option. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, endotracheal tube, expected discomfort, and management strategies.

The parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should include which of the following? a. Parents can meet all the child's needs. b. Child needs opportunities to play with peers. c. Constant parental supervision is needed to avoid overexertion. d. Child needs to understand that peers' activities are too strenuous.

ANS: B The child needs opportunities for social development. Children are able to regulate and limit their activities based on their energy level. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence.

Which muscle is contraindicated for the administration of immunizations in infants and young children? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Anterolateral thigh

ANS: B The dorsogluteal site is avoided in children because of the location of nerves and veins. The deltoid is recommended for 12 months and older. Ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants.

The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which of the following complications? a. Hypoxemia b. Right-to-left shunt of blood c. Decreased workload on left side of heart d. Pulmonary vascular congestion

ANS: D In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein, resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion. Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased workload on the left side of the heart with a PDA.

Which of the following is descriptive of most cases of hemophilia? a. X-linked recessive deficiency of platelets causing prolonged bleeding b. X-linked recessive inherited disorder in which a blood clotting factor is deficient c. Autosomal dominant deficiency of a factor involved in the blood-clotting reaction d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped

ANS: B The inheritance pattern in 80% of all the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease). The disorder involves coagulation factors, not platelets. The disorder does not involve red cells or the Y chromosome.

Ventricular septal defect has the following blood flow pattern: a. Mixed blood flow b. Increased pulmonary blood flow c. Decreased pulmonary blood flow d. Obstruction to blood flow from ventricles

ANS: B The opening in the septal wall allows for blood to flow from the higher pressure left ventricle into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect.

The nurse notices that a child is increasingly apprehensive and has tachycardia after heart surgery. The chest tube drainage is now 8 ml/kg/hr. Which of the following should be the nurse's initial intervention? a. Apply warming blankets. b. Notify the practitioner of these findings. c. Give additional pain medication per protocol. d. Encourage child to cough, turn, and deep breathe.

ANS: B The practitioner is notified immediately. Increases of chest tube drainage to more than 3 ml/kg/hr for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative hemorrhage. Increased chest tube drainage with apprehensiveness and tachycardia may indicate cardiac tamponade—blood or fluid in the pericardial space constricting the heart—which is a life-threatening complication. Warming blankets are not indicated at this time. Additional pain medication can be given before the practitioner drains the fluid, but the notification is the first action. Encouraging the child to cough, turn, and deep breathe should be deferred until after evaluation by the practitioner.

A child with sickle cell anemia (SCA) develops severe chest and back pain, fever, a cough, and dyspnea. The first action by the nurse is to: a. administer 100% oxygen to relieve hypoxia. b. notify practitioner, since chest syndrome is suspected. c. infuse intravenous antibiotics as soon as cultures are obtained. d. give ordered pain medication to relieve symptoms of pain episode.

ANS: B These are the symptoms of chest syndrome, which is a medical emergency. Notifying the practitioner is the priority action. Oxygen may be indicated; however, it does not reverse the sickling that has occurred. Antibiotics are not indicated initially. Pain medications may be required, but evaluation by the practitioner is the priority.

A father calls the clinic because he found his young daughter squirting Visine eye drops into her mouth. Which of the following is the most appropriate nursing action? a. Reassure the father that Visine is harmless. b. Direct him to seek immediate medical treatment. c. Recommend inducing vomiting with ipecac. d. Advise him to dilute Visine by giving his daughter several glasses of water to drink.

ANS: B Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary. Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk.

SELECT ALL THAT APPLY. The nurse is caring for a child with Kawasaki disease in the acute phase. Which of the following clinical manifestations would the nurse expect to observe? a. Osler nodes b. Cervical lymphadenopathy c. Strawberry tongue d. Chorea e. Erythematous palms f. Polyarthritis

ANS: B, C, E Clinical manifestations of Kawasaki disease in the acute phase include cervical lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? A.An elevated hemoglobin level B.A decreased reticulocyte count C.An elevated RBC count D.Red blood cells that are microcytic and hypochromic

Answer: D The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

SELECT ALL THAT APPLY. The nurse is caring for children on an adolescent-only unit. Which of the following growth and development milestones would the nurse expect from 13- and 14-year-old children? a. Self-centered with increased narcissism b. No major conflicts with parents c. Established abstract thought process d. Have a rich, idealistic fantasy life e. Highly value conformity to group norms f. Secondary sexual characteristics appear

ANS: B, E, F Growth and development milestones in the 11- to 14-year-old age-group include minimal conflicts with parents (compared with the 15- to 17-year-old age-group), a high value placed on conformity to the norm, and the appearance of secondary sexual characteristics. Self-centeredness and narcissism are seen in the 15- to 17-year-old age-group, along with a rich and idealistic fantasy life. Abstract thought processes are not well established until the 18- to 20-year-old age-group.

Decreasing the demands on the heart is a priority in care for the infant with congestive heart failure (CHF). In evaluating the infant's status, which of the following is indicative of achieving this goal? a. Irritability when awake b. Capillary refill of more than 5 seconds c. Appropriate weight gain for age d. Positioned in high Fowler position to maintain oxygen saturation at 90%

ANS: C Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the CHF. Irritability is a symptom of CHF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation.

In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling and delay the vasooclusion and hypoxia-ischemia cycle. The nurse teaches the parents to: a. encourage drinking. b. keep accurate records of output. c. check for moist mucous membranes. d. monitor the concentration of the child's urine.

ANS: C Children with SCA have impaired kidney function and cannot concentrate urine. Parents are taught signs of dehydration and ways to minimize loss of fluid to the environment. Encouraging drinking is not specific enough for parents. The nurse should give the parents and child a target fluid amount for each 24-hour period. Accurate monitoring of output may not reflect the child's fluid needs. Without the ability to concentrate urine, the child needs additional intake to compensate. Dilute urine and specific gravity are not valid signs of hydration status in children with SCA.

Which of the following statements best describes β-thalassemia major (Cooley anemia)? a. It is an acquired hemolytic anemia. b. Inadequate numbers of red blood cells (RBCs) are present. c. Increased incidence occurs in families of Mediterranean extraction. d. It commonly occurs in individuals from West Africa.

ANS: C Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. Thalassemia is inherited as an autosomal recessive disorder. An overproduction of RBCs occurs. Although numerous, the red cells are relatively unstable. Sickle cell disease is common in blacks of West African descent.

The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following? a. Administer oxygen. b. Record data on nurses' notes. c. Report data to the practitioner. d. Place child in high Fowler position.

ANS: C One of the earliest signs of CHF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible CHF. Although oxygen or a semiupright position may be indicated, the first action is to report the data to the practitioner.

The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about home care. The initial therapy for a joint injury is: a. nonsteroidal antiinflammatory drugs (NSAIDs). b. DDAVP (synthetic vasopressin). c. intravenous (IV) infusion of factor VIII concentrates. d. elevation and application of ice to involved joint.

ANS: C Parents are taught home infusion of factor VIII concentrate. For moderate and severe hemophilia, prompt IV administration is essential to prevent joint injury. NSAIDs are effective for pain relief. They must be given with caution because they inhibit platelet aggregation. A factor VIII level of 30% is necessary to stop bleeding. DDAVP can raise the factor VIII level fourfold. Moderate hemophilia is defined by a factor VIII activity of 4.9. A fourfold increase would not meet the 30% level. Ice and elevation are important adjunctive therapy, but factor VIII is necessary.

The nurse is concerned with the prevention of communicable disease. Primary prevention results from which of the following? a. Hand washing b. Strict isolation c. Immunizations d. Early diagnosis

ANS: C Primary prevention rests almost exclusively with immunizations. Hand washing and isolation are control measures to prevent the spread of disease. Early diagnosis assists in instituting appropriate therapy when available and in preventing spread to others.

A mother states that she brought her child to the clinic because the 3-year-old girl was not keeping up with her siblings. During physical assessment, the nurse notes that the child has pale skin and conjunctiva and has muscle weakness. The hemoglobin on admission is 6.4 g/dl. After notifying the practitioner of the results, the nurse's priority intervention is to: a. reduce environmental stimulation to prevent seizures. b. have the laboratory repeat the analysis with a new specimen. c. minimize energy expenditure to decrease cardiac workload. d. administer intravenous fluids to correct the dehydration.

ANS: C The child has a critically low hemoglobin value. The expected range is 11.5 to 15.5 g/dl. When the oxygen-carrying capacity of the blood decreases slowly, the child is able to compensate by increasing cardiac output. With the increasing workload of the heart, additional stress can lead to cardiac failure. Reduction of environmental stimulation can help minimize energy expenditure, but seizures are not a risk. A repeat hemoglobin analysis is not necessary. The child does not have evidence of dehydration. If intravenous fluids are given, they can further dilute the circulating blood volume and increase the strain on the heart.

The clinical manifestations of sickle cell anemia (SCA) are primarily the result of which of the following? a. Decreased blood viscosity b. Deficiency in coagulation c. Increased red blood cell (RBC) destruction d. Greater affinity for oxygen

ANS: C The clinical features of SCA are primarily the result of increased RBC destruction and obstruction caused by the sickle-shaped RBCs. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. SCA does not have a coagulation deficit. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension.

A child with severe anemia requires a unit of red blood cells (RBCs). The nurse explains to the child that the transfusion is necessary to: a. allow her parents to come visit her. b. fight the infection that she now has. c. increase her energy so she will not be so tired. d. help her body stop bleeding by forming a clot (scab).

ANS: C The indication for RBC transfusion is risk of cardiac decompensation. When the number of circulating RBCs is increased, tissue hypoxia decreases, cardiac function is improved, and the child will have more energy. Parental visiting is not dependent on transfusion. The decrease in tissue hypoxia will minimize the risk of infection. There is no evidence that the child is currently infected. Forming a clot is the function of platelets.

Which of the following is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead poisoning? a. Maintain bed rest. b. Maintain isolation precautions. c. Keep accurate record of intake and output. d. Institute measures to prevent skeletal fracture.

ANS: C The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. The chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result from high levels lead.

Which of the following should the nurse include when teaching the mother of a 9-month-old infant about administering liquid iron preparations? a. Give with meals. b. Stop immediately if nausea and vomiting occur. c. Adequate dosage will turn the stools a tarry green color. d. Allow preparation to mix with saliva and bathe the teeth before swallowing.

ANS: C The nurse should prepare the mother for the anticipated change in the child's stools. If the iron dose is adequate, the stools will become a tarry green color. A lack of color change may indicate insufficient iron. The iron should be given in two divided doses between meals when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced and gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth; they should be administered through a straw and the mouth rinsed after administration.

Which of the following is an important consideration for the school nurse planning a class on injury prevention for adolescents? a. Adolescents generally are not risk takers. b. Adolescents can anticipate the long-term consequences of serious injuries. c. Adolescents need to discharge energy, often at the expense of logical thinking. d. During adolescence, participation in sports should be limited to prevent permanent injuries.

ANS: C The physical, sensory, and psychomotor development of adolescents provides a sense of strength and confidence. There is also an increase in energy coupled with risk taking that puts them at risk. Adolescents are risk takers because their feelings of indestructibility interfere with understanding of consequences. Sports can be a useful way for adolescents to discharge energy. Care must be taken to avoid overuse injuries.

After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. The nurse should do which of the following? a. Elevate affected extremity. b. Notify practitioner of the observation. c. Record data on assessment flow record. d. Apply warm compresses to insertion site.

ANS: C The pulse distal to the catheterization site may be weaker for the first few hours after catheterization, but should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are not indicated.

When caring for the child with Kawasaki disease, the nurse should know which of the following? a. Aspirin is contraindicated. b. Principal area of involvement is the joints. c. Child's fever is usually responsive to antibiotics within 48 hours. d. Therapeutic management includes administration of gamma globulin and salicylates.

ANS: D High-dose intravenous gamma globulin and salicylate therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is responsive to antiinflammatory doses of aspirin and antipyretics.

Acyclovir (Zovirax) is given to children with chickenpox to: a. minimize scarring. b. prevent aplastic anemia. c. prevent spread of the disease. d. decrease the number of lesions.

ANS: D Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching, lethargy, and anorexia. Treating pruritus and discouraging itching minimizes scarring. Aplastic anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents spread of disease.

The nurse is preparing a pamphlet for parents of adolescents about guidance during the adolescent years. Which of the following suggestions should the nurse include in the pamphlet? a. Provide criticism when mistakes are made or when views are different. b. Use comparisons to older siblings or extended family to promote good outcomes. c. Begin to disengage from school functions to allow the adolescent to gain independence. d. Provide clear, reasonable limits and define consequences when rules are broken.

ANS: D An anticipatory guideline to include when teaching parents of adolescents is to provide clear, reasonable limits and have clear consequences when rules are broken. Parents should avoid criticism when mistakes are made and should allow opportunities for the teen to voice different views and opinions. Parents should try to avoid comparing the teen to a sibling or extended family member. Parents should try to be more engaged in the teen's school functions to show support and unconditional love.

A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that the x-ray film will do which of the following? a. Show bones of chest but not the heart b. Evaluate the vascular anatomy outside of the heart c. Show a graphic measure of electrical activity of the heart d. Provide information on heart size and pulmonary blood flow patterns

ANS: D Chest x-ray films provide information on the size of the heart and pulmonary blood flow patterns. The bones of the chest are visible on the chest x-ray film, but the heart and blood vessels are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography.

According to Piaget, adolescents tend to be in which stage of cognitive development? a. Concrete operations b. Conventional thought c. Postconventional thought d. Formal operational thought

ANS: D Cognitive thinking culminates in the capacity for abstract thinking. This stage, the period of formal operations, is Piaget's fourth and last stage. Concrete operations usually occur between ages 7 and 11 years. Conventional and postconventional thought refers to Kohlberg's stages of moral development.

Which of the following is true concerning the development of autonomy during adolescence? a. Development of autonomy typically involves rebellion. b. Development of autonomy typically involves parent-child conflicts. c. Parent and peer influences are opposing forces in the development of autonomy. d. Conformity to both parents and peers gradually declines toward the end of adolescence.

ANS: D During middle and late adolescence the conformity to parents and peers declines. Subjective feelings of self-reliance increase steadily over the adolescent years. The adolescent has genuine behavioral autonomy. Rebellion is not typically part of adolescence. It can occur in response to excessively controlling circumstances or to growing up in the absence of clear standards. Parent and peer relationships can play complementary roles in the development of a healthy degree of individual independence.

The nurse suspects that a child has ingested some type of poison. Which of the following clinical manifestations would be most suggestive that the poison was a corrosive product? a. Tinnitus b. Disorientation c. Stupor, lethargy, coma d. Edema of lips, tongue, pharynx

ANS: D Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system.

Which of the following statements best describes iron deficiency anemia in infants? a. It is caused by depression of the hematopoietic system. b. It is easily diagnosed because of infant's emaciated appearance. c. It results from a decreased intake of milk and the premature addition of solid foods. d. Clinical manifestations are related to a reduction in the amount of oxygen available to tissues.

ANS: D In iron deficiency anemia the child's clinical appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic system is not depressed. The bone marrow produces red cells that are smaller and contain less hemoglobin than normal red cells. Children who are iron deficient from drinking excessive quantities of milk are usually pale and overweight. They are receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive intake of milk.

Adolescents often do not use reasoned decision making when issues such as substance abuse and sexual behavior are involved. This is because they: a. tend to be immature. b. do not need to use reasoned decision making. c. lack cognitive skills to use reasoned decision making. d. are dealing with issues that are stressful and emotionally laden.

ANS: D In the face of time pressures, personal stress, or overwhelming peer pressure, young people are more likely to abandon rational thought processes. Many of the health-related decisions adolescents confront are emotionally laden or new. Under such conditions, many people do not use their capacity for formal decision making. The majority of adolescents have cognitive skills and are capable of reasoned decision making. Stress affects their ability to process information. Reasoned decision making should be used in issues that are crucial such as substance abuse and sexual behavior.

The infant with congestive heart failure (CHF) has a need for: a. decreased fat. b. increased fluids. c. decreased protein. d. increased calories.

ANS: D Infants with CHF have a greater metabolic rate because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and increased fat to facilitate the child's intake of sufficient calories. Fluids must be carefully monitored because of the CHF.

For children who do not have a matched sibling bone marrow donor, the therapeutic management of aplastic anemia includes: a. antibiotics. b. antiretroviral drugs. c. iron supplementation. d. immunosuppressive therapy.

ANS: D It is thought that aplastic anemia may be an autoimmune disease. Immunosuppressive therapy, including antilymphocyte globulin, antithymocyte globulin, cyclosporine, granulocyte colony-stimulating factor, and methylprednisone, has greatly improved the prognosis for patients with aplastic anemia. Antibiotics are not indicated as the management. They may be indicated for infections. Antiretroviral drugs and iron supplementation are not part of the therapy.

A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which of the following? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia

ANS: D Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic consequence of hydrocarbon ingestion.

A 3-month-old infant has a hypercyanotic spell. The nurse's first action should be which of the following? a. Assess for neurologic defects. b. Prepare family for imminent death. c. Begin cardiopulmonary resuscitation. d. Place child in the knee-chest position.

ANS: D The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.

The therapeutic management of children with β-thalassemia major consists primarily of which of the following? a. Oxygen therapy b. Supplemental iron c. Adequate hydration d. Frequent blood transfusions

ANS: D The goal of medical management is to maintain sufficient hemoglobin (>9.5 g/dl) to prevent bone marrow expansion. This is achieved through a long-term transfusion program. Oxygen therapy and adequate hydration are not beneficial in the overall management of thalassemia. The child does not require supplemental iron. Iron overload is a problem because of frequent blood transfusions, decreased production of hemoglobin, and increased absorption from the gastrointestinal tract.

The school nurse is teaching a class on injury prevention. Which of the following should be included when discussing firearms? a. Adolescents are too young to use a gun properly for hunting. b. Gun carrying among adolescents is on the rise, primarily among inner-city youth. c. Nonpowder guns (air rifles, BB guns) are a relatively safe alternative to powder guns. d. Adolescence is the peak age for being a victim or offender in the case of injury involving a firearm.

ANS: D The increase in gun availability in the general population is linked to increased gun deaths among children, especially adolescents. Gun carrying among adolescents is on the rise and not limited to the stereotypic inner-city youth. Adolescents can be taught to safely use guns for hunting, but they must be stored properly and used only with supervision. Nonpowder guns (air rifles, BB guns) cause almost as many injuries as powder guns.

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of which of the following complications? a. Air embolism b. Allergic reaction c. Hemolytic reaction d. Circulatory overload

ANS: D The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema are signs and symptoms of allergic reactions. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.

The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following? a. Notify the physician. b. Place child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above catheterization site.

ANS: D When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified and a new bandage with more pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. Trendelenburg position would not be a helpful intervention. It would increase the drainage from the lower extremities.

The school nurse sees a 14-year-old child who presents with fatigue and a nagging cough of three weeks' duration that has become productive with thick mucus and is much worse at night. The school nurse suspects pertussis (whooping cough), because vaccine protection wanes in 5-10 years. What is the school nurse's first nursing action? A) Isolate the child and contact the parents. B) Report the case to the Centers for Disease Control and Prevention (CDC). C) Encourage fluids to prevent dehydration. D) Provide emotional support to parents.

Answer: A Isolation is necessary to prevent the disease from spreading to classmates by aerosolized droplet infection. The case is not reportable until a positive culture is returned. The remaining interventions are important, but are not the first nursing action, because the entire school population might be at risk.

Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client's family to recognize and report which of the following? A.Yellowing of the skin B.Constipation C.Abdominal distention D.Puffiness around the eyes

Answer: A Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.

Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? A.Child's reluctance to move a body part B.Cool, pale, clammy extremity C.Eccymosis formation around a joint D.Instability of a long bone in passive movement

Answer: A Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child's reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis.

Which of the following situations increase risk of lead poisoning in children? a. playing in the park with heavy traffic and with many vehicles passing by b. playing sand in the park c. playing plastic balls with other children d. playing with stuffed toys at home

Answer: A Lead poisoning may be caused by inhalation of dusk and smoke from leaded gas. It may also be caused by lead-based paint, soil, water (especially from plumbings of old houses).

Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease? a. Polycythemia b. Cardiomyopathy c. Endocarditis d. Low blood pressure

Answer: A The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation.

SELECT ALL THAT APPLY. Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? A."He drinks over 3 cups of milk per day." B."I can't keep enough apple juice in the house; he must drink over 10 ounces per day." C."He refuses to eat more than 2 different kinds of vegetables." D."He doesn't like meat, but he will eat small amounts of it." E."He sleeps 12 hours every night and take a 2-hour nap."

Answer: A, B. Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.

A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with: A. Gastric lavage B. Chelating agents C. Antiemetics D. Activated charcoal

Answer: B Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Answers A and D are used to remove noncorrosive poisons; therefore, they are incorrect. Answer C prevents vomiting; therefore, it is an incorrect response.

The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which of the following? a) Anemia. b) Peripheral hypoxia. c) Delayed physical growth. d) Destruction of bone marrow.

Answer: B Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to tissue changes in the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as the body attempts to improve blood supply. Clubbing of the fingers is associated with polycythemia, not anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues. The child may be small for his or her chronological age, but clubbing does not result from slow physical growth. Destruction of the bone marrow is not related to this congenital heart malformation. Instead, bone marrow is actively producing erythrocytes to compensate for the chronic hypoxia.

Which of the following nursing interventions should be implemented for a client with influenza? a) instructing family members not to visit the client until the fever declines b) instructing family members or visitors to wear surgical mask before entering the client's room c) instructing family members that there are no special precautions needed when caring for the client d) instructing family members to wear gown and gloves before entering the client's room

Answer: B Influenza requires droplet precaution. Healthcare workers and family members should wear surgical mask when entering client's room to ensure prevention of contamination.

The nurse concludes that a parent of an otherwise healthy child with varicella (chickenpox) has an accurate understanding of the disease when the parent states which of the following? A) "I will take my child to our primary care provider to request acyclovir." B) "I will send my child back to school when all the lesions are dry and crusted over." C) "I will give my child acetaminophen 120 mg three times a day for the duration of the illness." D) "I will take my child to our primary care provider to request antibiotics."

Answer: B Varicella is no longer contagious when all the lesions are dry. Acetaminophen should be used when the child has a fever, not three times per day, every day, during the illness. Antibiotics are not effective against viruses. Acyclovir is an antiviral, but it is recommended for immunocompromised children, not healthy children and adolescents.

A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease? A.Platelet count B.Hematocrit level C.Reticulocyte count D.Hemoglobin level

Answer: C A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? A.Autoimmune reaction complicated by hypoxia B.Lack of oxygen in the red blood cells C.Obstruction to circulation D.Elevated serum bilirubin concentration

Answer: C Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

Which of the following would the nurse identify as the priority nursing diagnosis during a toddler's vasoocclusive sickle cell crisis? A.Ineffective coping related to the presence of a life-threatening disease B.Decreased cardiac output related to abnormal hemoglobin formation C.Pain related to tissue anoxia D.Excess fluid volume related to infection

Answer: C For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusive and subsequent tissue ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vasoocclusive crisis. Typically, a sickle cell crisis can be precipitated by a fluid volume deficit or dehydration.

Which of the following disorders results from a deficiency of factor VIII? A.Sickle cell disease B.Christmas disease C.Hemophilia A D.Hemophilia B

Answer: C Hemophilia A results from a deficiency of factor VIII. Sickle cell disease is caused by a defective hemoglobin molecule. Christmas disease, also called hemophilia B, results in a factor IX deficiency.

A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease? a) cracked lips b) a normal appearance c) conjunctival hyperemia d) desquamation of the skin

Answer: C In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

A 16 month old child diagnosed with Kawasaki Disease (KD) is very irritable,refuses to eat, and exhibits peeling skin on the hands and feet. Which of the following would the nurse interpret as the priority? a) applying lotions to the hands and feet b) offering foods the toddler likes c) placing the toddler in a quiet environment d) encouraging the parents to get some rest

Answer: C One of the characteristics of children with KD is irritability. They are often inconsolable.Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. The child's irritability takes priority over peeling of the skin.

A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? A.Infection B.Trauma C.Fluid overload D.Stress

Answer: C Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.

A 10-year-old child has just received his first immunization of influenza vaccine. His lips begin to swell, and he states, "It feels like my throat is closing shut and my chest is tight when I breathe." The nurse recognizes these as signs of which of the following? A) A common systemic allergic reaction to immunization B) A local allergic reaction to the influenza vaccine injection C) A life-threatening reaction to the influenza vaccine D) An anxiety reaction due to receiving an injection

Answer: C This child's reaction describes angioedema, laryngeal edema, and respiratory distress, indicating impending anaphylactic shock. All other answer choices are possible reactions to immunizations, but are non-life-threatening.

A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion? A.Hemophilia is a Y linked hereditary disorder B.Males inherit hemophilia from their fathers C.Females inherit hemophilia from their mothers D.Hemophilia A results from a deficiency of factor VIII

Answer: D Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

A client with hemophilia has a very swollen knee after falling from bicycle. Which of the following is the first nursing action? a) initiate an IV site to begin administration of cryoprecipitate b) type and cross-match for possible transfusion c) monitor the client's vital signs for the first 5 minutes d) apply ice pack and compression dressings to the knee

Answer: D Rest, ice, compression, and elevation (RICE )are the immediate treatments to reduce the swelling and bleeding into the joint. These are the priority actions for bleeding into the joint of a client with hemophilia.

The mothers asks the nurse why her child's hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate? A."The placenta bars passage of the hemoglobin S from the mother to the fetus." B."The red bone marrow does not begin to produce hemoglobin S until several months after birth." C."Antibodies transmitted from you to the fetus provide the newborn with temporary immunity." D."The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."

Answer: D Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first? a) obtain an order for sedation for the child b) assess for an irregular heart rate and rhythm c) explain to the child that it will only hurt for a short time d) place the child in knee-to-chest position

Answer: D. the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart rate and rhythm. Explaining tho the child that it will only hurt for a short time does nothing to alleviate hypoxia.

The school nurse is concerned about an outbreak of chickenpox because two children at the school have cancer and are immunodeficient from chemotherapy. The nurse should recommend which of the following? a. No precautions necessary b. Acyclovir (Zovirax) to minimize symptoms of chickenpox c. Varicella-zoster immune globulin to prevent chickenpox d. Temporarily stopping chemotherapy to allow immune system to recover

Varicella-zoster immune globulin is given to high-risk children to prevent the development of chickenpox. Precautions are necessary. In immunocompromised children, varicella can have significant morbidity and mortality. Acyclovir decreases the severity, not the incidence, of chickenpox. The children are already immunocompromised from the previous round of chemotherapy. Stopping the chemotherapy may allow their white and red blood cell counts to improve, but prophylaxis is necessary.