Practice Questions Exam 3

A nurse is assessing a toddler with vesicoureteral reflux. What clinical finding does the nurse expect to identify? A. Dysuria B. Oliguria C. Glycosuria D. Proteinuria

A. Dysuria Discomfort during urination (dysuria) is a symptom of a urinary tract infection (UTI), which is common with vesicoureteral reflux. During voiding, urine is swept up the ureters and then flows back to the bladder, resulting in a residual volume that provides a medium for the development of a UTI. Oliguria, glycosuria, and proteinuria usually do not occur with vesicoureteral reflux.

A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? A. Cold, clammy skin B. Increased pulse rate C. Increased blood pressure D. Cyanosis of the nail beds

B. Increased pulse rate Increased pulse rate (tachycardia) occurs as the body tries to compensate for hypoxia due to mild iron deficiency anemia. Severe anemia however can manifest as pale, cool, and clammy skin. Increased blood pressure is not a response associated with anemia. Cyanosis of the nail beds is a sign of carbon monoxide poisoning.

Which of these age groups has the highest incidence of lead poisoning? A. Adult B. Toddler C. Adolescent D. School-age child

B. Toddler The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and because of their increased level of oral activity, put objects into their mouths. Adults have a greater risk of cardiovascular or pulmonary disease. Drowning and motor vehicle accidents are more common among adolescents. Bicycle accidents are more common among school-aged children.

At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the nurse's priority action in response to this situation? A. Stimulate crying B. Substitute sterile water for the formula C. Suction and then oxygenate the newborn D. Stop the feeding momentarily and then restart it

C. Suction and then oxygenate the newborn Cyanosis, choking, and coughing are signs of aspiration and hypoxia. Suctioning and oxygenation are needed. Crying may add to the distress. Water could be aspirated, worsening the problem. Stopping the feeding momentarily and then restarting it is unsafe; the newborn is showing signs of a blocked airway.

An infant has had surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? A. Frequent crying B. Bulging fontanels C. Change in vital signs D. Difficulty with feeding

B. Bulging fontanels After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge. Frequent crying may be a typical pattern for the neonate; it does not, in and of itself, indicate changes in ICP. Changes in vital signs are not among the early signs of increasing ICP in an infant. Difficulty with feeding can indicate changes in ICP but is not one of the initial signs.

The nurse is teaching the parents of a toddler-age client about food safety related to choking. Which parental statement indicates the need for further education? A. "Hot dogs are safe and do not present a choking hazard for my child." B. "Ice cream is safe and does not present a choking hazard for my child." C. "Chicken nuggets are safe and do not present a choking hazard for my child." D. "Mashed potatoes are safe and do not present a choking hazard for my child."

A. "Hot dogs are safe and do not present a choking hazard for my child." Large round foods, such as hot dogs, should be avoided until the toddler is able to chew effectively due to the risk for choking. Ice cream, chicken nuggets, and mashed potatoes are not identified as choking hazards for the toddler-age client.

A 7-year-old child was recently found to have juvenile idiopathic arthritis. The parents are concerned about the lifelong effects of the disorder and are investigating other therapies to use with the medications. What referral should the nurse recommend? A. Physical therapy B. Special education C. Nutritional therapy D. Herbal supplements

A. Physical therapy A physical therapist can prescribe an exercise protocol to keep the joints as mobile as possible; a routine can be developed to help the child alleviate morning stiffness. Special education might be necessary in the future; there is no evidence that it is needed at this time. Although nutrition is an appropriate part of therapy, it is the physical therapy program that can most directly influence movement. Over-the-counter medications should not be used without the supervision of a healthcare provider.

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? A. pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) B. pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L) C. pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L) D. pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L)

A. pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO3- will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO2 ranges from 35 to 45 mm Hg, and HCO3- ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.

What is the priority of preoperative nursing care for an infant with a cleft lip? A. Preventing crying B. Modifying feeding C. Preventing infection D. Minimizing handling

B. Modifying feeding Because of the anomalous structure of the upper lip, the infant with cleft lip may have difficulty sucking on a nipple. Adaptive shields are available for breastfeeding. Haberman feeders and other modified devices are used for formula feeding. Preventing crying is not an immediate concern; after surgery it becomes necessary to help prevent tension on the suture line. Cleft palate, not cleft lip, may predispose the infant to infection. The infant should be cuddled and held.

The nurse takes into consideration that the effect PKU has on the infant's development will depend primarily upon which factor? A. Blood phenylalanine levels in utero B. Excessive levels of epinephrine at birth C. Diagnosis within the first 2 days after birth D. Adherence to a corrective diet instituted early

D. Adherence to a corrective diet instituted early In phenylketonuria (PKU), adherence to a specific diet is necessary for optimal physical growth with little or no adverse effects on mental development; a diet that is instituted late will not reverse brain damage. The fetus does not have an excessive level of phenylalanine. Although PKU can be detected in the fetus with genetic studies, an excessive level of phenylalanine first becomes measurable several days after the neonate starts feeding. The epinephrine levels are decreased, not increased. Tyrosine, an amino acid produced by the metabolism of phenylalanine, is absent in PKU; tyrosine is needed to form epinephrine. Two days after birth is too soon to make a diagnosis of PKU. Detection cannot happen until the infant has taken milk or formula that contains phenylalanine for 24 hours and metabolites have accumulated in the blood. Behaviors indicating mental retardation and central nervous system involvement are usually evident by about 6 months of age in the untreated infant.

The day after undergoing abdominal appendectomy a school-aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation? A. Providing a rest period B. Offering a reward for walking C. Encouraging use of the spirometer D. Administering the prescribed pain medication

D. Administering the prescribed pain medication Children in pain resist any activity that increases their pain. The child is more likely to cooperate with activities that promote recovery if pain is being addressed. Children will rest spontaneously when tired. A reward may be helpful if the child is uncooperative, but it will not be beneficial if the child is in pain. Although use of the spirometer is an important postoperative activity, use of the device before walking is unnecessary. Walking not only helps aerate the lungs but also hastens peristalsis.

A nurse is teaching a 10-year-old child with type 1 diabetes about insulin requirements. When does the nurse explain that insulin needs will decrease? A. When puberty is reached B. When infection is present C. When emotional stress occurs D. When active exercise is performed

D. When active exercise is performed Exercise reduces the body's need for insulin. Increased muscle activity accelerates transport of glucose into muscle cells, thus producing an insulinlike effect. With increased growth and associated dietary intake, the need for insulin increases during puberty. An infectious process may require increased insulin. Emotional stress increases the need for insulin.

What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? A. A low-phenylalanine diet is required. B. Phenylalanine is not necessary for growth. C. Phenylalanine can be administered to correct the deficiency. D. A substitute for phenylalanine is an increased amount of other amino acids.

A. A low-phenylalanine diet is required. Reducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There is no substitute for phenylalanine, which is one of the essential amino acids.

Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis? A. Log-rolling every 2 hours B. Checking the dressing frequently C. Supervising deep-breathing exercises D. Maintaining the adolescent in the supine position for 3 days

A. Log-rolling every 2 hours Log-rolling is necessary to prevent movement of the newly aligned and instrumented vertebrae and should be done frequently to prevent skin breakdown. Dressings are checked frequently in all postoperative clients; this action is nonspecific. Coughing and deep-breathing are done by most postoperative clients; this action is nonspecific. The client who has had a spinal fusion may be turned and still be protected from injury with log-rolling. Remaining in one position for 3 days could lead to skin breakdown from unrelieved pressure.

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? A. Encouraging fluids B. Monitoring for seizures C. Measuring abdominal girth D. Checking for pupillary reactions

B. Monitoring for seizures Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

An 11-year-old child with juvenile idiopathic arthritis will be receiving continued nonsteroidal antiinflammatory drug (NSAID) therapy at home. Which important toxic effect of NSAIDs must be included in the nurse's discharge instructions to the child and family? A. Diarrhea B. Hypothermia C. Blood in the urine D. Increased irritability

C. Blood in the urine Hematuria may result from the use of NSAIDs because they may cause nephrotoxicity. Diarrhea can occur but is not a sign of toxicity. Hypothermia does not occur with NSAIDs. Drowsiness, not hyperactivity, may occur.

Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? A. Kinking of the bowel onto itself B. A band of connective tissue compressing the bowel C. Telescoping of a proximal loop of bowel into a distal loop D. A protrusion of an organ or part of an organ through the wall that contains it

C. Telescoping of a proximal loop of bowel into a distal loop Intussusception is the telescoping or prolapse of a segment of the bowel into the lumen of an immediately connecting segment of the bowel. Volvulus is a twisting of the bowel onto itself. Adhesions are bands of scar tissue that can compress the bowel. Herniation describes protrusion of an organ through the wall that contains it.

What is the priority of care for a 7-year-old child with recently diagnosed celiac disease? A. Preventing celiac crisis and resulting problems B. Minimizing complications of respiratory involvement C. Teaching the parents to establish a diet that promotes optimal growth D. Helping the parents and child adjust to the long-term dietary restrictions

D. Helping the parents and child adjust to the long-term dietary restrictions Adherence to dietary restrictions can prevent future complications and celiac crisis. Celiac crisis usually develops as a result of nonadherence to the diet, so adherence to the diet, rather than preventing celiac crisis, is the primary objective. Respiratory involvement is not a primary problem with celiac disease. Teaching the parents to establish a growth-encouraging diet is incorrect because, regardless of adherence to the diet, the disease may interfere with the expected growth rate.

The nurse is providing discharge instructions to the parents of a child who has undergone surgical correction of hypospadias. What is the priority information for the nurse to include? A. Ensuring that the child's privacy is maintained B. Increasing the time that the catheter is clamped C. Maintaining the surgically implanted tension device D. Teaching parents how to care for the catheterization system

D. Teaching parents how to care for the catheterization system Parents should know how to empty the urine bag and how to prevent kinking of the tubing. Although the child's privacy is important, the priority is maintaining the flow of urine through the indwelling catheter. The indwelling catheter is never clamped because backup pressure could disturb the suture line. There is no tension device.

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching? A. "I'll use a straight razor when I start shaving." B. "I plan on trying out for the swim team next year." C. "If I injure a joint, I'll keep it still, elevate it, and apply ice." D. "If I get a little scratch, I can apply gentle pressure for 10 to 15 minutes."

A. "I'll use a straight razor when I start shaving." A straight razor should not be used by the adolescent with hemophilia, so further teaching is required. The adolescent with hemophilia should be taught to use an electric razor for shaving. Contact sports should be avoided, but swimming is a recommended activity, so trying out for the swim team indicates that the adolescent understands the teaching. If a superficial injury occurs, gentle, prolonged pressure should be applied until the bleeding has stopped. If a muscle or joint injury occurs, the area should be immobilized, elevated, and iced. Both statements indicate that the adolescent has understood the teaching.

The urinary output of a 9-year-old child with acute glomerulonephritis decreases to 250 mL/24 hr. A diet low in sodium and potassium is prescribed. What should the nurse encourage the child to have for lunch? A. Baked chicken, green beans, and lemonade B. Cream of tomato soup, salami sandwich, and cola C. Grilled cheese sandwich, sliced tomatoes, and milk D. Peanut butter and jelly sandwich, celery, and orangeade

A. Baked chicken, green beans, and lemonade The foods in this grouping have the least sodium and potassium. Cream of tomato soup, a salami sandwich, and cola are high in sodium; some colas also have a high potassium content. A grilled cheese sandwich, sliced tomatoes, and milk are high in sodium. Celery is high in sodium; the sodium content is moderately high in bread and peanut butter.

A 6-year-old child is hospitalized with nephrotic syndrome. The mother asks the nurse what she may bring for her child to play with during the hospitalization. In light of the child's age, what should the nurse suggest? Select all that apply. A. Checkers B. Wooden Puzzles C. Paper and crayons D. Simple card games E. CDs

A. Checkers C. Paper and crayons D. Simple card games Six-year-old children enjoy the competition involved in playing checkers and simple card games and also the challenge to their intellectual ability. They are also creative, and coloring is a quiet activity that is age appropriate and enjoyable. Wooden puzzles are more appropriate for toddlers. Listening to CDs is more appropriate for an older child.

The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? A. Holding may meet needs and reduce tension on the suture line. B. Sedation limits activity and decreases tension on the suture line. C. Handling may increase irritability, causing tension on the suture line. D. Arm movements cannot be controlled, placing tension on the suture line.

A. Holding may meet needs and reduce tension on the suture line. Touching and cuddling provide a sense of well-being and relieve strain on the suture line that results from restlessness and crying. It is inappropriate to sedate an infant for its calming effect or to decrease activity. Careful handling will not damage the suture line. Arm movement can be controlled by applying elbow restraints to prevent the infant's hands from touching the suture line.

A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? A. Hypoxia B. Hyperthermia C. Emotional trauma D. Aspiration pneumonia

A. Hypoxia The degree of hypoxia experienced by the child will determine the extent of neurological, liver, and renal damage. The child was hypothermic, not hyperthermic. Although emotional trauma can be overwhelming, it usually does not influence the ultimate physical prognosis as the extent of the hypoxia does. Although aspiration pneumonia may be severe initially, it does not result in long-term sequelae as hypoxia can.

The mother of a school-aged child with type 1 diabetes asks why it was recommended that her child use an insulin pump rather than insulin injections. What will the nurse tell the mother concerning the greatest advantage of the insulin pump? A. Independence is fostered. B. Fear of daily injections is allayed. C. Dietary restrictions are minimized. D. Blood glucose monitoring can be eliminated.

A. Independence is fostered. Continuous insulin therapy allows the child to become independent of parental control and anxiety regarding insulin injections. The pump can be programmed to give a bolus of insulin, which corresponds to food eaten, rather than the child needing an injection because of a sudden increase in blood glucose. The pump requires a subcutaneous needle insertion site that needs periodic changing (e.g., every third day or as necessary). The child must still adhere to the recommended diet; dietary control minimizes the amount of exogenous insulin needed. Blood glucose monitoring is required regardless of the method of insulin administration.

The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding? A. Joints B. Abdomen C. Cerebrum D. Epiphyses

A. Joints Activity can result in bleeding in children with hemophilia; therefore weight-bearing joints, especially the knees, are the most common site of bleeding. The abdomen is usually protected from the trauma of direct force. The cerebrum is protected by the skull and is not likely to be injured. Bleeding from bones themselves is not common without other associated trauma.

The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern? A. Marked irritability B. Complaints of pain C. Pulse of 100 beats/min D. Temperature of 99.4° F (37.4° C)

A. Marked irritability Marked irritability may be a sign of malfunction of the shunt or infection and should be reported immediately. Complaints of pain are expected after surgery. A pulse rate of 100 beats/min is within the expected range (70 to 110 beats/min) for children between the ages of 2 and 10 years. A low-grade fever is expected after the stress of surgery.

Which priority actions should the nurse implement when providing care to a toddler-age child who presents in the emergency department (ED) after an accidental overdose? Select all that apply. A. Monitor vital signs B. Assess mental status C. Question the parents D. Initiate CPR, if needed E. Empty mouth of remnants

A. Monitor vital signs B. Assess mental status D. Initiate CPR, if needed The priority nursing actions when providing care to a toddler-age client who presents in the ED after an accidental overdose include monitoring vital signs, assessing mental status, and initiating CPR, if needed. Clearing the mouth of remnants and questioning the parents are not the priority actions by the nurse in this situation.

The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? A. Notify the practitioner, because circumoral pallor may indicate cardiac problems B. Notify the practitioner, because both signs are indicative of increased intracranial pressure C. Take no specific action, because both signs are expected in a newborn until 2 weeks of age D. Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying

A. Notify the practitioner, because circumoral pallor may indicate cardiac problems Although acrocyanosis (cyanotic hands and feet) is common in the newborn, circumoral pallor is not a normal newborn finding. Circumoral pallor is one sign of cardiac pathology and indicates a need for further assessment and investigation by the healthcare provider. Neither circumoral pallor nor acrocyanosis is a sign of increased intracranial pressure. Circumoral pallor is not expected in the newborn; it may indicate cardiac pathology.

The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? A. Shunting of blood from right to left B. Shunting of blood from left to right C. Obstruction of blood flow from the left side of the heart D. Obstruction of blood flow between the left and right sides of the heart

A. Shunting of blood from right to left Right-to-left shunting results in inadequate perfusion of blood; not enough blood flows to the lungs for oxygenation. Left-to-right shunting results in too much blood flowing to the lungs; blood is adequately perfused. Left-sided obstruction to the flow of blood results in decreased peripheral pulses, not cyanosis. Obstruction of blood flow between the left and right sides of the heart usually occurs with patent ductus arteriosus. There should be no shunting of blood between the right and left sides of the heart after the ductus arteriosus has closed. If the ductus remains open, the shunting is from left to right, and cyanosis is not a factor.

An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting? A. Start with small, frequent feedings. B. Rock for 20 minutes after a feeding. C. Keep the infant awake for 30 minutes after feeding. D. Position the infant flat on the right side during feedings.

A. Start with small, frequent feedings. Starting with small feedings will decrease the risk of vomiting. Rocking, keeping the infant awake, and positioning the infant horizontally all increase the chance of vomiting.

An infant with congenital hypothyroidism receives levothyroxine for three months. During the return appointment, which statement by the mother indicates to the nurse that the drug is effective? A. The infant is alert and interactive. B. The skin is cool to the touch. C. The baby's fine tremor has ceased. D. The baby's thyroid stimulating hormone level has increased.

A. The infant is alert and interactive. Infants with congenital hypothyroidism are lethargic and may even need to be awakened and stimulated to nurse; therefore, an infant who is alert and interacts appropriately for its age would demonstrate improvement. Cool skin is a clinical sign of hypothyroidism related to a slow basal metabolic rate. Fine hand tremor is related to hyperthyroidism and is not present in an infant with hypothyroidism, even one whose condition is being stabilized with levothyroxine. An increased thyroid stimulating hormone level would indicate inadequate treatment.

Which are sources of lead the nurse should assess for when providing care to a toddler-age client who is admitted with lead poisoning? Select all that apply. A. Water B. Pottery C. Stained glass D. Collectable toys E. Vinyl miniblinds

A. Water B. Pottery D. Collectable toys E. Vinyl miniblinds Water, pottery, collectable toys, and vinyl miniblinds are all sources of lead that should be included in the nurse's assessment for a toddler-age client who is admitted with lead poisoning. The making of stained glass, not stained glass itself, is a source of lead.

The nurse is reviewing discharge instructions for a mother whose lactose intolerant school-aged child was recently found to have celiac disease. Which statements by the mother demonstrate understanding of the child's nutritional needs? Select all that apply. A. "Rolled-up lunch meat with cheese is a good alternative to sandwiches." B. "I'll try to provide meals that are lower in fats and higher in carbohydrates." C. "I'll start giving her milk with meals so she gets enough calcium in her diet." D. "She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse." E. "I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein."

B. "I'll try to provide meals that are lower in fats and higher in carbohydrates." D. "She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse." E. "I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein." Celiac disease is characterized by bowel irritation on exposure to protein gluten. Dietary management generally consists of a diet high in protein and carbohydrates and low in fats. When the bowel is inflamed, high-fiber foods should be avoided; this includes carrots. Gluten is added to many foods as hydrolyzed vegetable protein; therefore the mother needs to read the ingredient list to identify the presence of this substance. Lunch meat should be avoided because it contains gluten. Since the child is also lactose intolerant, milk also needs to be avoided.

While performing preoperative teaching a nurse explores a young adolescent's concern about changes in appearance after surgery to correct scoliosis. What is the most appropriate statement by the nurse? A. "After surgery your back will be much straighter." B. "You're concerned about how you'll look after surgery." C. "Many teenagers who have this type of surgery do very well." D. "Your parents think it's important for you to have this surgery."

B. "You're concerned about how you'll look after surgery." By saying, "You're concerned about how you'll look after surgery," the nurse is using the technique of paraphrasing to encourage the adolescent to expand on personal concerns, which may relieve anxiety. Adolescents tend to be focused on the present, not the future; the nurse should focus on the adolescent's current concerns. Focusing on others is not client-centered care; the nurse should focus on the adolescent.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply. A. Raw carrots B. Boiled spinach C. Dried apricots D. Brussels sprouts E. Asparagus spears

B. Boiled spinach C. Dried apricots According to the nutritional table, the food sources highest in iron are, "Liver and muscle meats, dried fruits (apricots), legumes, dark green leafy vegetables (spinach), whole-grain and enriched bread and cereals, and beans." Although carrots, Brussels sprouts, and asparagus spears contain some iron, they are not considered high sources of iron.

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? A. Offering clear fluids whenever the child is awake B. Checking the child's level of consciousness hourly C. Assessing the child's blood pressure every four hours D. Administering the prescribed oral antibiotic medication

B. Checking the child's level of consciousness hourly Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation. The child is too ill to ingest anything by mouth; also, vomiting is likely. Hydration is maintained intravenously. Taking the blood pressure and other vital signs every four hours is insufficient monitoring; many changes can occur in this time span. Intravenous antibiotics have a rapid systemic effect and are preferable to those administered by way of the oral route.

A 4-year-old child with nephrotic syndrome is admitted to the pediatric unit. What clinical finding does the nurse expect when assessing this child? A. Severe lethargy B. Dark, frothy urine C. Chronic hypertension D. Flushed, ruddy complexion

B. Dark, frothy urine Dark, frothy urine is characteristic of a child with nephrotic syndrome; large amounts of protein in the urine cause it to take this appearance. The child may be somewhat, not severely, lethargic. Blood pressure is normal or decreased; hypertension is associated with glomerulonephritis. Children with nephrotic syndrome usually have a pale complexion and are not flushed and ruddy in appearance.

During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? A. Diapers should be changed at least every 4 hours B. Frequent diaper changes with cleansing are needed. C. Medicated ointment should be applied six times a day. D. Powder may be used in the perineal area when it becomes wet.

B. Frequent diaper changes with cleansing are needed. Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the healthcare provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.

A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis (painful episode). What are the priority nursing concerns? Select all that apply. A. Nutrition B. Hydration C. Pain management D. Prevention of infection E. Oxygen supplementation

B. Hydration C. Pain management E. Oxygen supplementation The triad of treatment for a client experiencing a sickle cell crisis is: hydration, oxygenation, and pain management. Hydration will provide more circulating volume for the sickled cells to move through. Supplemental oxygen will provide more oxygen molecules to attach to the red cells, providing more oxygen to the tissue and joints. Pain management is typically the primary reason this client presents for treatment. The pain becomes unbearable. Other interventions such as nutrition and keeping the client safe from infection should be addressed but are not priorities.

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? A. Nausea B. Lethargy C. Sunset eyes D. Hyperthermia

B. Lethargy Lethargy is an early sign of a changing level of consciousness; changing level of consciousness is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occur in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases.

An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period? A. Ensuring that privacy is maintained B. Minimizing pain with adequate analgesia C. Restricting fluid intake until the stent is removed D. Gradually increasing the time that the urinary catheter is clamped

B. Minimizing pain with adequate analgesia Although analgesia is important to minimize pain, it also relaxes the infant, who may be immobilized to maintain the position of the urethral stent and to ensure optimal healing of the newly formed urethra. Infants are accustomed to a lack of privacy because of the need to expose the perineum and touch the genitalia when cleaning the area. Fluid intake should be encouraged, not restricted. The indwelling catheter is not clamped; backup pressure could disturb the suture line.

A toddler-age child presents in the emergency department (ED) with an infected wound. The child's mother states, "I don't have time to take care of this." A review of the child's medical record indicates that each appointment related to the wound was cancelled. Which should the nurse suspect based on the current data? A. Physical abuse B. Physical neglect C. Emotional neglect D. Psychologic abuse

B. Physical neglect Physical neglect involves the deprivation of necessities, such as food, clothing, shelter, supervision, medical care, and education. The deliberate infliction of physical injury on a child, usually by the child's caregiver, is termed physical abuse. Emotional neglect generally refers to failure to meet the child's needs for affection, attention, and emotional nurturance. Psychologic abuse is a form of emotional neglect.

A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis? A. Colonoscopy B. Rectal biopsy C. Multiple saline enemas D. Fiberoptic nasoenteric tube

B. Rectal biopsy A full-thickness rectal biopsy involves the removal of some rectal tissue, which is examined microscopically for the absence of ganglion cells. A colonoscopy is not necessary to obtain a rectal biopsy specimen. A saline enema may relieve the obstruction, but it is not a definitive diagnostic tool; a barium enema may be used for diagnosis after the age of 2 months. A fiberoptic nasoenteric tube is not used to identify the cause of intestinal obstruction in infants.

A toddler is found to have coarctation of the aorta. What does the nurse expect to identify when taking the child's vital signs? A. Irregular heartbeat B. Weak femoral pulse C. Thready radial pulses D. Increased temperature

B. Weak femoral pulse Coarctation of the aorta is a narrowing of the aorta, usually in the thoracic segment, resulting in decreased blood flow below the constriction and increased blood volume above it. The femoral pulses are weak or absent. An irregular heartbeat and increased temperature are not related to coarctation of the aorta. The radial pulses are bounding in coarctation of the aorta.

The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him two baby aspirins?" What is the best response by the nurse? A. "You seem concerned about giving drugs to your child." B. "It's all right to give him baby aspirin when he hurts himself." C. "Aspirin may cause more bleeding. Give him acetaminophen instead." D. "He should be given acetaminophen every day. It'll prevent bleeding."

C. "Aspirin may cause more bleeding. Give him acetaminophen instead." Aspirin, which has an anticoagulant effect, is contraindicated because it may harm a child with bleeding problems; in addition, aspirin is contraindicated for all children because of its relationship to Reye syndrome. Stating that the parent seems concerned about giving drugs to the child does not answer the mother's question and may cause the mother to feel defensive. Acetaminophen cannot prevent bleeding episodes; it is an analgesic.

A 4-year-old child who barely survived a near-drowning episode is in critical condition in the pediatric intensive care unit. Suddenly the child opens her eyes and smiles, prompting a parent to say to the nurse, "Look! I think she'll get better now." What is the best response by the nurse? A. "You're right; that's a very good sign." B. "Try to have your child hold your hand." C. "We're doing everything we can to promote recovery." D. "God certainly must be watching over your child today."

C. "We're doing everything we can to promote recovery." The nurse must emphasize that everything possible is being done because the outcome cannot be predicted at this time. Encouraging the parent's positive interpretation of the child's reflexive behavior raises false hope. Telling the parent that God is watching over the child constitutes false hope. The parent's statement did not ask for the nurse's religious viewpoint; if the child does not improve, the parent may then perceive that God is not watching over the child.

After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What assessment should the nurse document that will aid confirmation of the diagnosis? A. Frequency of crying B. Amount of oral intake C. Characteristics of stools D. Absence of bowel sounds

C. Characteristics of stools Because intussusception creates intestinal obstruction in which the intestine "telescopes" and becomes trapped, passage of intestinal contents is lessened; stools are red and look like currant jelly because of the mixing of stool with blood and mucus. Frequency of crying is not specific to a diagnosis of intussusception. Accurate intake and output records are important, but they are not essential for confirming this diagnosis. Bowel sounds will not be affected significantly with intussusception.

A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant? A. Giving the oral feedings slowly B. Reporting vomiting to the practitioner C. Checking the patency of the nasogastric tube D. Monitoring the child for signs of infection at the incision site

C. Checking the patency of the nasogastric tube A nasogastric tube is used after surgery to decompress the stomach and limit tension on the suture line. As another means of limiting pressure on the suture line, oral feedings should not be implemented in the immediate postoperative period when the nasogastric tube is in place. Vomiting indicates obstruction of the nasogastric tube; this is why the initial action should be to check the patency of the tube. It is too soon for signs of infection to occur.

A nurse is caring for a 3-week-old infant with hypertrophic pyloric stenosis who is severely dehydrated. What finding does the nurse expect when assessing the infant? A. Weight loss of 5% B. Severe allergic reactions C. Depressed anterior fontanel D. Urine specific gravity of 1.014

C. Depressed anterior fontanel Depressed fontanels related to decreased cerebral spinal fluid are a classic sign of fluid volume deficiency in infants. A 5% weight loss indicates mild dehydration; a severely dehydrated infant will have a 15% weight deficit. Dehydration is unrelated to allergic reactions. This specific gravity is within the expected limits of 1.005 to 1.020.

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply. A. Displaying sensitivity about their child care ability B. Taking the initiative in meeting their child's needs C. Exhibiting difficulty in showing concern for their child D. Demonstrating heightened interest in their child's welfare E. Procrastinating in obtaining treatment for their child's injuries

C. Exhibiting difficulty in showing concern for their child E. Procrastinating in obtaining treatment for their child's injuries Abusive parents seek gratification of their own needs rather than of their child's needs; they may even project blame for the abuse on their child and find it difficult to conceal their hostility. Abusive parents often delay obtaining help for their child's injuries; the behavior is precipitated by a concern to conceal the injury and a lack of concern for the child. Abusive parents typically have an ill-developed nurturing role and little perception of their parenting inability.

Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? A. How to obtain the vital signs daily B. Date on which to return to prepare for renal dialysis C. Instructions about which high-sodium foods to avoid D. List of activities that will encourage the child to remain active

C. Instructions about which high-sodium foods to avoid Sodium is usually limited to control or prevent edema or hypertension until the child is asymptomatic. The child is usually on a regular diet with sodium restrictions (e.g., salty snacks [potato chips, pretzels, tortilla chips] and hot dogs, bacon, bologna, and other processed meats). It is not necessary to check the vital signs daily, but the healthcare provider may suggest weighing the child daily. Usually recovery from APSGN is complete. The condition does not cause such severe kidney damage that dialysis is necessary. The child should not be kept active, because rest is needed until the child is asymptomatic.

A 3-month-old infant with tetralogy of Fallot is admitted for a diagnostic workup in preparation for corrective surgery. The morning after cardiac catheterization the infant suddenly becomes cyanotic and begins breathing rapidly. In what position should the nurse immediately place the infant? A. Supine B. Lateral C. Knee-chest D. Semi-Fowler

C. Knee-chest The infant is experiencing a hypercyanotic ("tet" spell) episode caused by a sudden decrease in pulmonary blood flow and an increase in right-to-left shunting. It usually occurs after increased activity. The knee-chest position decreases venous return from the legs, which increases systemic vascular resistance, thereby increasing pulmonary blood flow. The supine and lateral positions increase venous return, which exacerbates the problem. Although the semi-Fowler position is recommended for infants with cardiac disease, it is not adequate for an infant experiencing a tet spell.

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? A. Negative C-reactive protein B. Increased reticulocyte count C. Positive antistreptolysin titer D. Decreased sedimentation rate

C. Positive antistreptolysin titer A positive antistreptolysin titer is present with rheumatic fever because of the previous infection with streptococci. An increased reticulocyte count is usually related to a decrease in mature red blood cells caused by hemorrhage or blood dyscrasias; it is unrelated to an infectious or inflammatory process. A positive, not a negative, C-reactive protein will be present; this is indicative of an inflammatory process. The erythrocyte sedimentation rate will be increased, not decreased, indicating the presence of an inflammatory process.

A young child from a developing country is admitted to the pediatric unit for surgery to correct a congenital heart defect. The mother asks the nurse why her child squats after exertion. The nurse responds, in language that the mother understands, that this position does what? A. Decreases the number of muscle aches B. Improves walking capacity and hip mobility C. Reduces how hard the heart must work D. Helps more blood return to the heart

C. Reduces how hard the heart must work When the child squats, blood pools in the lower extremities because of hip and knee flexion which causes less blood to return to the heart and reduces how hard the heart must work (cardiac workload). For this young child, squatting after exertion does not reduce muscle aches, it is unrelated to walking capacity and hip mobility, and it decreases (not increases) blood return to the heart.

A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? A. Decreased tremors B. Increased hours of sleep C. Weight loss during next 2 days D. More rapid heart rate within 2 days

C. Weight loss during next 2 days Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure. Tremors are not typical in infants with heart disease. Tremors are related to central nervous system irritability. If the infant's condition improved, energy would increase and sleeping needs would decrease. Tachycardia is a sign of congestive heart failure. The purpose of the cardiotonic is to slow the heart rate.

A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after NPH insulin administration does the insulin peak? A. 1 to 2 hours B. 2 to 4 hours C. 5 to 10 hours D. 4 to 12 hours

D. 4 to 12 hours NPH insulin onset is 1.5 to 4 hours, peaks in 4 to 12 hours with a duration of 12 to 18 hours.

An infant with a cardiac defect is fed in the semi-Fowler position. After the nurse feeds and burps the infant and changes the infant's position, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. Which activity most likely caused the infant's response? A. Burping B. Feeding C. Position change D. Bowel movement

D. Bowel movement During a bowel movement the Valsalva maneuver can occasionally initiate a hypercyanotic spell ("tet spell," "blue spell") by inducing an increase in intrathoracic pressure, a decrease in the return of blood to the heart, an increase in venous pressure, and a decrease in heart rate. Burping does not influence cardiovascular function. Although feeding can cause fatigue and increase the heart rate, it will not precipitate such an immediate response as the one described in the scenario. Likewise, a position change will not precipitate such an immediate response.

The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected? A. Neurological B. Integumentary C. Gastrointestinal D. Cardiopulmonary

D. Cardiopulmonary Muscle degeneration is advanced in the adolescent with Duchenne muscular dystrophy. The disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life-threatening respiratory infections and heart failure. Central nervous system function is not affected by Duchenne muscular dystrophy; nor is the integumentary system. Nutritional problems related to the gastrointestinal system are less significant than cardiopulmonary problems.

A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable long-term effect of the condition if treatment is not begun immediately? A. Myxedema B. Thyrotoxicosis C. Spastic paralysis D. Cognitive impairment

D. Cognitive impairment Congenital hypothyroidism is the result of insufficient secretion by the thyroid gland because of an embryonic defect. A decreased level of thyroid hormone affects the fetus before birth during cerebral development, so it is likely that there will be some cognitive impairments at birth. Treatment before 3 months of age will prevent further damage. Congenital hypothyroidism does not become myxedema. Thyrotoxicosis is another term for hyperthyroidism. Although it is not expected, it may occur with an overdose of exogenous thyroid hormone, but it is too soon to discuss this possibility with the parents. Spastic paralysis occurs only if the infant has cerebral palsy.

An 8-year-old child is being discharged after recovery from a sickle cell vaso-occlusive (painful crisis) episode. The nurse teaches the parents the do's and don'ts of the child's care. What statement by the parents satisfies the nurse that they understand the principles of care? A. Have the child schooled by a private tutor B. Restrict the child's fluid intake during the night C. Permit the child to play with just one peer at a time D. Encourage the child to engage in low-intensity activities

D. Encourage the child to engage in low-intensity activities Low-intensity activities should be encouraged, because strenuous exercise leads to increased cellular metabolism, resulting in tissue hypoxia, which can precipitate sickling. Hiring a tutor is detrimental to the child's developmental needs and may result in social isolation. Some parents restrict fluids at night to discourage bedwetting. However, fluids should not be restricted in this case because keeping the child well hydrated helps prevent sickling. Restricting the child's play activities is unnecessary unless the other children have an infectious disease; a variety of peer relationships should be encouraged.

What should the plan of care for a newborn with hypospadias include? A. Preparing the infant for insertion of a cystostomy tube B. Explaining to the parents the genetic basis for the defect C. Keeping the infant's penis wrapped with petrolatum gauze D. Giving the parents reasons why circumcision should not be performed

D. Giving the parents reasons why circumcision should not be performed The parents need to know why circumcision should not be performed. The foreskin may be needed for repair and reconstruction of the penis. A cystostomy tube is not inserted, because there is no interference with voiding. Hypospadias is not a genetic disorder, although there appears to be some evidence that it is familial. The penis is generally wrapped in petrolatum gauze after, not before, surgical correction of hypospadias.

A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? A. Increasing fluids B. Administering oxygen C. Giving a tepid sponge bath D. Instituting droplet precautions

D. Instituting droplet precautions Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort.

After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond? A. The diameter of the aorta is enlarged. B. The wall between the right and left ventricles is open. C. It is a narrowing of the entrance to the pulmonary artery. D. It is a connection between the pulmonary artery and the aorta

D. It is a connection between the pulmonary artery and the aorta Before birth, oxygenated fetal blood is shunted directly into the systemic circulation by way of the ductus arteriosus, a connection between the pulmonary artery and the aorta. After birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. Occasionally, particularly in preterm infants, this vessel remains open, a condition known as patent ductus arteriosus. Enlargement of the diameter of the aorta is not the problem in patent ductus arteriosus. A defective wall between the right and left ventricles is a description of ventricular septal defect. A narrowing of the entrance to the pulmonary artery is a description of pulmonic stenosis.

An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure? A. Medicating the infant for pain B. Placing the infant in a high Fowler position C. Positioning the infant on the side that has the shunt D. Monitoring the infant for increasing intracranial pressure

D. Monitoring the infant for increasing intracranial pressure The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid and increased intracranial pressure. Although providing pain relief for the infant is an important part of postsurgical care, monitoring for potentially severe complications such as increased intracranial pressure takes precedence. Positioning the infant flat helps prevent complications that may result from a too-rapid reduction of intracranial fluid. The infant is positioned off the shunt to prevent pressure on the valve and incision area.

A nurse is preparing an infant for a lumbar puncture. In what position should the nurse hold the infant? A. Sitting with the buttocks at the table's edge and the head flexed B. Prone with the head extended over the table's wedge and the extremities swaddled C. Lateral recumbent with the back at the table's edge and the head and legs extended D. Side-lying with the back at the table's edge and the head flexed with the knees brought to the chin

D. Side-lying with the back at the table's edge and the head flexed with the knees brought to the chin The side-lying position with the head and hips flexed separates the vertebrae, making needle insertion easier; it also permits better restraint by the nurse. The sitting position is used at times for adults; it is not recommended for infants or children because of the difficulty in keeping them still. The prone position prevents the head from being flexed and the spine curved outward for the insertion of the needle. The lateral recumbent position is unacceptable; it does not cause the spine to curve.

A child with hip dysplasia has undergone a closed reduction surgery. The nurse assesses the child 2 days after the surgery and feels that the treatment and care provided for the child were not effective. The nurse made this conclusion based on what findings? A. The child has a staggering gait. B. The child is unable to walk independently. C. The child has impaired muscle tone and flexibility. D. The child's femoral head did not return to the hip socket.

D. The child's femoral head did not return to the hip socket. The nurse and health care professionals set realistic outcomes and evaluate them regularly to determine the quality and effectiveness of the treatment. During closed reduction surgery, the surgeon fits the femoral head into the hip socket. If the laboratory reports indicate that the femoral head did not return to the hip socket, it implies that the surgery was ineffective and useless. The child may have a staggering gait for a few weeks after the surgery; this does not indicate that the surgery was ineffective. The child may experience pain after the surgery and may require support to walk. The child will be in a spica cast for 6 months after the surgery and, because of this, the child may temporarily lose muscle tone and flexibility. Therefore these outcomes do not indicate that the treatment was ineffective or useless.

A 5-year-old client has recently been diagnosed with type 1 diabetes. A glucose tolerance test is prescribed. The prescription reads, "Administer glucose 1g/kg." The client weighs 60 pounds. How much glucose should the nurse administer in grams? Record your answer using a whole number. ___ g

27 g

The mother of a 5-year-old girl child reports to a nurse that her daughter has a genital discharge and recurrent urinary tract infections. What should the nurse suspect from the mother's statement? A. The child may be a victim of sexual abuse. B. The child may be a victim of physical abuse. C. The child may be a victim of physical neglect. D. The child may be a victim of emotional neglect.

A. The child may be a victim of sexual abuse. Genital discharge and recurrent urinary tract infections are signs of sexual abuse. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.

An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? A. Cyanosis B. Restlessness C. Decreased heart rate D. Increased respiratory rate

D. Increased respiratory rate Because the lungs are stressed by pulmonary edema, a quicker respiratory rate is the first and most reliable indicator of early heart failure in infants. Cyanosis is a late sign of heart failure; with early failure there is still adequate perfusion of blood. Infants with early heart failure do not move about; they become fatigued quickly, especially when feeding, because of a decrease of oxygen to body cells. The heart rate of an infant in early heart failure increases, not decreases, in an attempt to increase oxygen to body cells.