Case Study 19: Pediatric Patients in Clinic and Acute Care Settings

Rebecca is a 6-year-old girl with cystic fibrosis. She arrives at the pediatric cystic fibrosis clinic for her routine 3-month appointment. The nurse obtains and calculates the following growth parameters: Weight, 33 lbs (15 kg) (< 5%); height, 42 in. (106 cm) (5%); and body mass index (BMI), 13 (< 5%). Her parents report specks of blood in her sputum after chest physiotherapy. Her forced expiratory volume in 1 second (FEV1) has decreased 25% from her last visit 3 months ago. Rebecca has clubbing of both her finger and toe nails. 24. How would the nurse best interpret Rebecca's decreased FEV1? 1. Decreased oxygenation 2. Increased obstruction 3. Presence of infection 4. Pulmonary remodeling

. Ans: 2 FEV1 measures the amount of air expired after 1 second of forced expiration. Thus a decrease in FEV1 indicates obstruction. As a result of obstruction, the child may have decreased oxygenation and carbon dioxide retention; however, FEV1 reflects obstruction and not oxygenation. FEV1 is not a method of determining pulmonary infection or pulmonary remodeling

Four-year-old Bobby is admitted to the pediatric unit with Kawasaki disease. Today is the seventh day of fever. Laboratory studies reveal a C-reactive protein level of 3.1 mg/dL (29.5 mmol/L) and a WBC count of 17,000 mm3 (17 × 10 9 /L). 30. Which pharmacologic intervention should the nurse anticipate at this time? 1. IV methylprednisolone 2. IV immunoglobulin 3. IV ibuprofen 4. IV infliximab

. Ans: 2 IV immunoglobulin is the first line of treatment for children with Kawasaki disease because it has been demonstrated to reduce the incidence of coronary artery aneurysms (which are life threatening). Methylprednisolone and infliximab are indicated for refractory Kawasaki disease. Ibuprofen may be administered for fever, which is a symptom of Kawasaki disease, but does not decrease the incidence of coronary aneurysm. Additionally, it usually is not administered intravenously.

10. Billy is to be transferred from the clinic to the hospital for his asthmatic condition. Which tasks are RN responsibilities and should not be delegated or performed by another member of the health care team? Select all that apply. 1. Give a report to the attending pediatrician at the receiving hospital. 2. Give a report to the charge nurse at the receiving hospital. 3. Help the parent and child to collect and bag up personal items. 4. Determine that the patient's condition is stable enough for transport to the hospital. 5. Assess the response to treatment and document the patient's condition. 6. Assist the patient when transferring to the ambulance stretcher

. Ans: 2, 5 The RN must give the nursing report to the receiving nurse and assess response to treatment and document the patient's condition. The pediatrician must give the physician-to-physician report and determine if the patient is stable enough for transfer. The RN can delegate to the AP: collecting of personal items and helping the patient to transfer. The RN must supervise and know that the AP has had proper training to handle patient belongings and in transfer techniques to prevent injury to self or patient

5. A parent calls in for advice because "Missy is 5 years old, and she just won't sleep in her own bed. For the past 4 months, she wakes and comes to sleep with me and my husband. She cries and cries if we take her back to her own room." What is the priority action? 1. Send the mother a brochure of things she can try to assist the child to sleep independently. 2. Advise the mother that this is a normal behavior that will eventually pass with time. 3. Suggest that the child be put back into her own bed and allowed to cry herself to sleep. 4. Schedule an appointment with the APN student for assessment and management.

. Ans: 4 Additional psychosocial and physical assessment is needed to intervene properly. The other three options may be appropriate after the initial assessment is completed.

Four-year-old Bobby is admitted to the pediatric unit with Kawasaki disease. Today is the seventh day of fever. Laboratory studies reveal a C-reactive protein level of 3.1 mg/dL (29.5 mmol/L) and a WBC count of 17,000 mm3 (17 × 10 9 /L). 29. Which nursing assessment is a priority? 1. Obtain a rectal temperature. 2. Auscultate the lungs. 3. Obtain a blood pressure. 4. Auscultate the heart.

. Ans: 4 Kawasaki disease is one of the most common causes of vasculitis in children and may result in cardiac complications. Early indications of cardiac involvement include tachycardia out of proportion to fever and a gallop rhythm; therefore auscultating the heart is the priority. It has already been established that this child has a fever; thus obtaining a rectal temperature is not a priority. Respiratory changes are not characteristic of complications of Kawasaki disease. Although shock is a complication of Kawasaki disease, hypotension is a late and ominous sign of shock in children. In fact, tachycardia is an earlier sign of shock in children, which further validates the need to auscultate the heart.

Terry is 7 months old; he rubs at both of his ears, acts fussy, refuses to suck, and has a temperature of 101.2°F (38.4°C). He has had three episodes of otitis media in the past. Social history includes night bottle-feeding and parents who smoke cigarettes 18. What is the priority nursing concern for Terry, who is rubbing at his ears, acting fussy, refusing to suck, and has a temperature of 101.2°F (38.4°C)? 1. Pain 2. Poor nutrition 3. Recurrent ear infections 4. Elevated temperature

Ans: 1 Acute otitis media is painful, and the child is demonstrating behaviors indicative of pain. Symptoms are relieved with acetaminophen and the application of a warm, moist towel to the outer ear. Poor nutrition and lack of fluid intake are concerns, but relief of pain will likely improve the child's willingness to suck and improve oral intake. The other concerns are pertinent but less urgent.

8. Which assessment finding for Billy is the most urgent and requires immediate intervention and notification of the pediatrician? 1. Sudden increase in respiratory rate and decreased breath sounds 2. Rattling cough productive of frothy, clear, gelatinous sputum 3. Crackles auscultated on inspiration in the lower lung fields 4. Restlessness and wheezing auscultated at the end of expiration

Ans: 1 An increased respiratory rate and decreased breath sounds are ominous signs of airway obstruction. Respiratory arrest is imminent. A productive cough warrants close observation because the patient is at risk for mucus plugs and bronchial spasm, which can cause an obstruction. Restlessness and wheezing are characteristic clinical manifestations of an asthma exacerbation and require attention but are not urgent. Crackles are suggestive of pneumonia and need to be monitored but are not the priority in this scenario. Respiratory arrest is the lifethreatening event that the nurse must address.

34. The nurse performs a pain assessment. Charlie rates his pain as 4 of 10 on the WongBaker FACES® Pain Rating Scale. Which intervention should the nurse implement? 1. Administer 200 mg of ibuprofen. 2. Administer 5 mg of hydrocodone. 3. Administer 100 mg of acetaminophen. 4. Administer 10 mg of codeine.

Ans: 1 Charlie is experiencing moderate pain for which 200 mg of ibuprofen is appropriate. The recommended dose of ibuprofen is 4 to 10 mg/kg/dose. Charlie weighs 21 kg, so the therapeutic dose range would be 84 mg to 210 mg; 200 mg is within the therapeutic range. Hydrocodone is for severe pain. Additionally, an adverse effect of hydrocodone is decreased gastrointestinal motility. Charlie is at risk for ileus, and administering hydrocodone will increase the risk. Although acetaminophen could also be administered for mild to moderate pain, the dose is too low. The therapeutic dose of acetaminophen is 10 to 15 mg/kg/dose. The therapeutic dose range based on Charlie's weight will be 210 to 315 mg per dose. Current recommendations by the American Academy of Pediatrics advise against codeine for pain. Codeine is metabolized in the liver to morphine. There is genetic variability in the activity of the hepatic enzyme (CYP2D6) that converts codeine to morphine; therefore, some children may have no effect from codeine, and some children may be highly sensitive to codeine.

25. What is the most likely cause of the specks of blood in Rebecca's sputum? 1. A sign of pulmonary infection 2. A sign of bronchial remodeling 3. A sign of gastric irritation 4. A sign of gastrointestinal bleeding

Ans: 1 Hemoptysis (the specks of blood in Rebecca's sputum) is a sign of pulmonary infection. Pulmonary infection erodes the pulmonary blood vessels, resulting in hemoptysis. Although there may be bleeding with gastric irritation, the presence of dark brown or black-colored blood suggests that hydrochloric acid in the stomach is breaking down RBCs and changing the appearance (denaturing) of the blood.

27. The nurse reviews Rebecca's growth chart and determines her weight and BMI have consistently remained below the 5th percentile. Which collaborative intervention is the nurse most likely to anticipate when planning teaching? 1. Preparing the child and family for potential gastrostomy tube placement 2. Focusing on increasing the child's intake of protein and calories 3. Suggesting an increased dosage of pancreatic enzymes 4. Preparing the child and family for potential total parenteral nutrition

Ans: 1 Lower BMI in children with cystic fibrosis is associated with poor pulmonary function. The need for increased calorie consumption and malabsorption characteristic of cystic fibrosis can often make it difficult for children to consume adequate calories for growth. This child has consistently been below the 5th percentile for both weight and BMI. In this case, alternative feeding routes such as gastrostomy tube feedings are considered. Total parenteral nutrition is not suitable for long-term management of nutritional deficits

35. At the change of shift, the nurse reassesses Charlie. His NG tube is patent and drained 120 mL over 12 hours. His oral temperature is 99.5°F (37.5°C), heart rate is 80 beats/min, and respiratory rate is 17 breaths/min. Charlie appears groggy and confused. Charlie's muscle strength is 3 of 5 in his upper and lower extremities. Laboratory tests are ordered. Which results are most consistent with Charlie's clinical presentation? 1. K+ , 3.3 mEq/L (3.3 mmol/L); Cl − , 95 mEq/L (95 mmol/L); pH, 7.55 2. K+ , 3.3 mEq/L (3.3 mmol/L); Cl − , 110 mEq/L (110 mmol/L); pH, 7.55 3. K+ , 5.2 mEq/L (5.2 mmol/L); Cl − , 110 mEq/L (110 mmol/L); pH, 7.20 4. K+ , 3.3 mEq/L (3.3 mmol/L); Cl − , 95 mEq/L (95 mmol/L); pH, 7.20

Ans: 1 NG suctioning can result in metabolic alkalosis, hypokalemia, and hypochloremia. Charlie's low respiratory rate, grogginess, and confusion are indicative of metabolic alkalosis. Metabolic alkalosis is further evidenced by increased pH. Muscle weakness is a sign of hypokalemia.

22. Which tasks related to the care of Sarah, Sam, and Ms. A can be delegated to the AP? Select all that apply. 1. Assist the toddler to eat an age-appropriate meal. 2. Apply a supportive splint to the infant's arm. 3. Report any behavioral signs of child abuse. 4. Report any findings to CPS if appropriate. 5. Assist by holding one child while the other is being examined. 6. Accompany the infant to the radiology department

Ans: 1, 3, 5, 6 The AP can hold one child, accompany the infant to radiology, and assist the toddler to eat. All caregivers should observe for and report signs of abuse. The AP will have less formal training in this area, but his or her input is still valuable. Any caregiver can contact CPS; however, in this case, the social worker is present and is the most appropriate person. If a social worker were not available, then the RN should assume this responsibility. The RN should apply the splint and assess for the 6 Ps (pain, pulse, paresthesia, paralysis, pallor, and poikilothermia [temperature control]) before and after the splint application.

28. Which laboratory value is consistent with the clubbing of Rebecca's finger and toe nails? 1. Elevated white blood cell (WBC) count 2. Elevated red blood cell (RBC) count 3. Decreased hematocrit 4. Decreased mean corpuscular volume

Ans: 2 Clubbing occurs with chronic arterial desaturation. Chronic arterial desaturation can result in polycythemia (increased RBCs). This would result in increased hematocrit, not a decrease. Increased WBCs are indicative of infection. Decreased mean corpuscular volume is associated with diseases that may affect formation of the RBCs such as microscopic anemia resulting from iron deficiency.

Sarah is 11 months old; she is dirty and crying, and her right arm is swollen and red. Sam is Sarah's 2-year-old brother; he is dirty and hungry and reaches out to be picked up. Ms. A, their mother, is 19 years old and single. She is thin and disheveled and seems somewhat confused. She is having trouble answering the nurse's questions. Ms. A says, "Those kids play too rough! The older one is always pushing the baby off the bed 21. What is the priority nursing concern in caring for the A family? (Refer to question 11 for a description of the A family's circumstances.) 1. Hygiene 2. Safety 3. Development 4. Growth

Ans: 2 Data suggest that Sarah may have an arm injury such as a fracture or sprain that will need intervention. Additionally, this type of injury is not consistent with Sarah's level of development, which raises the question of abuse or neglect. The other concerns also need to be addressed for the long-term benefit of this family, but the most immediate concern is the acute injury to Sarah's arm

2. A mother brings her 12-month-old child to the clinic for an influenza vaccination. The RN tells the mother that the child is also due for doses of measles-mumps-rubella, varicella, and hepatitis A vaccines. The mother declines the nurse's advice because "he has already had enough of those." What is the priority action? 1. Encourage a follow-up appointment and notify Child Protective Services (CPS). 2. Assess the mother's concerns and current level of knowledge about immunization. 3. Emphasize the benefits of immunization; explain the purpose and schedule. 4. Respect the mother's decision and alert the pediatrician to the situation.

Ans: 2 First the nurse should assess the mother's decision and her level of knowledge. She may not understand the pharmacology of immunizations, or the child may have had a problem with previous immunizations. She has agreed to immunizations in the past, but now something has changed her mind. Other options may be appropriate depending on the assessment findings

James is 3 years old. He woke last night with a sore throat, difficulty swallowing, and a fever. He is flushed, anxious, and drooling. The nurse observes a thick, muffled quality to his voice and slow, quiet breathing. The nurse notes that James looks sick 12. What is the priority concern for James? 1. Fever 2. Drooling 3. Sore throat 4. Flushing

Ans: 2 James has symptoms of epiglottitis and is at high risk for an airway obstruction. Drooling is a classic symptom of epiglottitis and indicates that airway obstruction may be imminent. The other data are relevant and support the epiglottitis diagnosis but do not indicate a need for immediate action

James is 3 years old. He woke last night with a sore throat, difficulty swallowing, and a fever. He is flushed, anxious, and drooling. The nurse observes a thick, muffled quality to his voice and slow, quiet breathing. The nurse notes that James looks sick 13. What is the priority action for James? 1. Visually inspect the throat with a tongue blade and auscultate the lungs. 2. Administer humidified oxygen and have the child sit upright on a parent's lap. 3. Notify the pediatrician and prepare intubation equipment. 4. Reassure the parents the symptoms will resolve with breathing of cool moist air.

Ans: 2 The child has an immediate need for oxygen. An upright position facilitates breathing, and parental comfort minimizes agitation and crying, which would increase oxygen consumption. Inspecting the throat is contraindicated because the procedure could exacerbate airway obstruction. Intubation equipment should always be available but is not needed yet; however, the pediatrician should be made aware of the child's drooling. (Note: If the clinic were attached to a hospital, the nurse could alert the operating room about the need for a potential emergency intubation, tracheostomy, or both.) Reassuring the parents that the condition will resolve spontaneously is inappropriate

6. Six-year-old Billy woke last night with dyspnea, restlessness, wheezing, and cough. Mother and child spent the night in a reclining chair. His mother declares, "He is having an asthma attack. We are both exhausted. I'm tired of waiting forever to see the doctor!" What is the priority nursing concern? 1. Billy's poor sleep quality and restlessness 2. Billy's ongoing shortness of breath 3. Mother's report of feeling exhausted 4. Mother's frustration with health care system

Ans: 2 The priority is the child's ongoing dyspnea, which indicates poor control of his asthma and possible hypoxemia. Additionally, restlessness is a clinical manifestation of impending respiratory failure. This requires rapid intervention. The mother's exhaustion should improve with treatment for the asthma attack. The mother's frustration with Billy's health care is important to address, but this is not immediately life threatening

3. A 9-month-old child arrives at the health center with his mother for immunizations. The child is fussy with rhinorrhea and has an axillary temperature of 100.4°F (38°C). The pediatrician has determined that the child has nasopharyngitis. What is the priority action? 1. Administer half of the immunizations and reschedule a subsequent appointment for the other half. 2. Advise the mother that fever is a contraindication for immunization and reschedule the appointment. 3. Administer acetaminophen to reduce fever and apply an anesthetic cream to the injection site. 4. Advise the mother that the child will likely need an antibiotic and reschedule the appointment.

Ans: 3 Acetaminophen will reduce the child's fever, and an anesthetic cream will reduce pain at the injection site. By taking this action, the nurse is preparing to give the child the recommended immunizations. Fever and minor illnesses are not contraindications for immunizations. Nasopharyngitis is a common cold that is caused by a virus, and antibiotics are not indicated for viruses. Additionally, antibiotics are not a contraindication for immunizations. Splitting immunizations is not recommended because it would result in immunization delay. The scheduling of immunizations is such that it protects children at times when they are most vulnerable to morbidity and mortality related to the natural diseases. Delayed immunization places the child at risk for vaccine-preventable diseases

7. As the nurse approaches Billy, which presentation would be of most concern and require immediate intervention? 1. Alert and irritable, lying recumbent on the examination table 2. Awake and nervous, sitting upright and crying, skin pale and dry 3. Agitated, sweating, and sitting upright with shoulders hunched forward 4. Asleep in a side-lying position breathing through open mouth

Ans: 3 Agitation and sweating are signs of severe respiratory distress. In addition, the child is attempting to maximize the thoracic cavity and to oxygenate more effectively by sitting upright and hunching forward

33. Charlie's parents ask the nurse if the NG tube can be removed because it is irritating Charlie's nose. What is the nurse's best response? 1. "The NG tube is necessary to prevent aspiration of the stomach contents into the lungs." 2. "The NG tube is necessary because Charlie will need to have feedings through it." 3. "The NG tube is necessary to keep Charlie's stomach empty, allowing the intestines to rest." 4. "The NG tube is necessary to prevent swallowed air from building up in the stomach."

Ans: 3 Charlie has decreased bowel sounds and a perforated appendix, which place him at risk for ileus. Insertion of an NG tube is recommended for gastric decompression.

Four-year-old Bobby is admitted to the pediatric unit with Kawasaki disease. Today is the seventh day of fever. Laboratory studies reveal a C-reactive protein level of 3.1 mg/dL (29.5 mmol/L) and a WBC count of 17,000 mm3 (17 × 10 9 /L). 31. After a 14-day hospitalization, Bobby is discharged home on a regimen of long-term aspirin therapy. What advice should the nurse provide regarding influenza vaccination? 1. The influenza vaccine is indicated for children 4 months to 18 years of age. 2. The influenza vaccine should be postponed for 11 months after treatment. 3. The influenza vaccine is indicated for children receiving long-term aspirin therapy. 4. The influenza vaccine should be postponed in children receiving long-term aspirin therapy.

Ans: 3 Children older than 6 months of age who are receiving long-term aspirin therapy should receive the influenza vaccine to prevent the risk of Reye syndrome. The influenza vaccine is not approved for children younger than 6 months of age. There is no need to postpone the vaccine. Immune globulin administration can decrease the effectiveness of live-virus vaccines; however, influenza is a conjugate vaccine and not a live-virus vaccine. Conjugate vaccines stimulate the immune response by introducing a piece of the pathogen

15. The pediatrician examines James and determines that he should be taken immediately to the Children's Hospital emergency department (ED). The child is breathing slowly and quietly; humidified oxygen is being administered. What is the priority action? 1. Instruct the parents to drive the child to the hospital immediately and call the ED. 2. Contact a private ambulance service and prepare the patient for transport. 3. Call 911, ask for advanced emergency medical services (EMS), and monitor the child. 4. Assist the pediatrician to intubate the child and then arrange for transport.

Ans: 3 In a clinic setting, calling 911 is the best and safest option. Directing the parent to drive would be considered dangerous malpractice. There is a wide variation in skill set among ambulance drivers, but advanced EMS paramedics that respond to 911 calls are routinely trained to intubate. Although the pediatrician is qualified to intubate, this is not a typical task in a clinic setting, and prophylactically intubating the child at this point would be inappropriate

James is 3 years old. He woke last night with a sore throat, difficulty swallowing, and a fever. He is flushed, anxious, and drooling. The nurse observes a thick, muffled quality to his voice and slow, quiet breathing. The nurse notes that James looks sick 14. The APN student and the pediatrician are at James' bedside. Which two additional team members would be the best combination to provide the initial care for James (refer to question 11)? 1. The experienced RN and the experienced LPN/LVN 2. The experienced RN and the AP 3. The experienced RN and the GN 4. The experienced LPN/LVN and the GN

Ans: 3 In addition to the APN student and the pediatrician, the best combination would be the experienced RN and GN. The child is acutely ill and may require immediate intervention for airway management. This is an opportunity for the experienced RN to closely supervise and mentor the GN. In the initial care of this child, there are few tasks that can be delegated to the AP, and the expertise of the LPN/LVN is best used to monitor and assess other patients in more stable conditions

4. A parent calls in for advice because her 18-month-old toddler has stumbled and bumped his head on the coffee table. Which symptom is cause for the greatest concern? 1. A swelling the size of a golf ball that is tender to the touch 2. Two episodes of vomiting a small amount of undigested food 3. Continuous crying for 2 hours, unrelieved by familiar comfort measures 4. Gaping 1.5-inch (4-cm) laceration on the forehead, with bleeding controlled by pressure

Ans: 3 Inconsolable crying for 2 hours is excessive, prolonged, and abnormal and may be a sign of increased intracranial pressure (ICP). Instruct the parent to call 911. The swelling can be treated with ice packs. Vomiting can be a sign of increased ICP, but fewer than three episodes is usually associated with minor injuries. A laceration on the forehead needs suturing, which should be done within several hours to prevent infection and reduce scarring, but the more pressing issue is to reaffirm with the caller that the bleeding is controlled.

The charge nurse is working in a large urban pediatric walk-in clinic that of ers well-baby care, provides immunizations, and is an educational resource for child health topics. In addition, the clinic also accommodates walk-in patients and of ers basic diagnostic testing and emergency care. The staf includes a pediatrician, a graduate student who is working toward an advanced practice nursing (APN) degree, an experienced RN, an experienced LPN/LVN, a pediatric social worker, a graduate nurse (GN), and an assistive personnel (AP). This morning, in addition to scheduled appointments, there is an immunization clinic. The charge nurse receives two phone calls, and there is one walk-in patient. 1. To ensure efficient workflow of the clinic and maximize available expertise, which task should be assigned to the experienced LPN/LVN? 1. Perform triage for walk-in patients. 2. Perform physical assessment of walk-in patients. 3. Give routine immunizations. 4. Obtain weight and height measurements

Ans: 3 LPN/LVN skills are appropriate for giving routine immunizations; the RN or GN could also give injections, but in a busy clinic the RN should perform triage and initial physical assessments and mentor the GN in these tasks. Obtaining height and weight should be delegated to the AP. The pediatrician will perform physical assessments of all walk-in patients and supervise the APN student, who can perform physical assessments and triage.

20. The GN is preparing to give an antibiotic tablet to 7-month-old Terry. She checks a drug reference book, crushes the tablet, and then mixes it into 3 oz (85 grams) of applesauce. As the supervising nurse, what is the priority action? 1. Accompany her into the room and observe while she administers the drug. 2. Allow her to proceed independently and ask her to report on the outcome. 3. Suggest that she consider again the patient's circumstances and developmental needs. 4. Suggest that she recheck the drug reference book before administering the drug.

Ans: 3 Remind the GN the infant is refusing to suck. Administering a crushed tablet in applesauce requires that the infant chew or suck and swallow. The GN can request that the pharmacy provide a liquid preparation of the medication. When administering liquid medication to an infant, the nurse positions the syringe toward the inside of the cheek and the back of the throat. The infant only needs to swallow the liquid. Mixing medication with applesauce is appropriate in some circumstances, but for this patient, the volume of 3 oz (85 grams) is excessive. In addition, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce new foods during an illness

Terry is 7 months old; he rubs at both of his ears, acts fussy, refuses to suck, and has a temperature of 101.2°F (38.4°C). He has had three episodes of otitis media in the past. Social history includes night bottle-feeding and parents who smoke cigarettes 19. For 7-month old Terry (refer to question 11), which task would be appropriate to assign to the LPN/LVN? 1. Teach parents that passive smoking and night bottles contribute to ear infections. 2. Explain the concept of "watchful waiting" for 72 hours for uncomplicated otitis. 3. Administer ordered dose of acetaminophen and apply a warm moist compress to pinna. 4. Prepare the child for a myringotomy and assist the pediatrician during the procedure.

Ans: 3 The LPN/LVN can administer medication and apply warm compresses for comfort. Teaching the parents about the impact of passive smoking and night bottles should be done by the RN. "Watchful waiting" is not usually done for infants of this age with bilateral otitis media but would certainly require teaching by the RN about what type of symptoms indicate that further treatment is needed. A myringotomy (surgical opening of the eardrum) would be performed after antibiotic treatment, if pain and infection did not resolve

Daisy is 4 years old; she is alert and irritable with pale, sweaty skin. An older neighbor who was temporarily watching Daisy reports that she was running around and playing, and then she got "grumpy." Daisy has diabetes, but the neighbor "was not sure how to give her the insulin." 16. Daisy (refer to question 11) has type 1 diabetes. She is currently alert but irritable. She looks pale and her skin is clammy. What is the priority action for Daisy? 1. Locate the mother to obtain a history and permission to treat. 2. Administer supplemental oxygen, alert the pediatrician, and establish IV access. 3. Ask the child to describe how she feels and use simple questions to obtain a history. 4. Perform blood glucose testing and then give the child a carton of milk.

Ans: 4 Based on the available information, the nurse would suspect and confirm hypoglycemia and then give food or fluids to prevent complications. According to the American Diabetes Association, milk is better than juice because the body's blood glucose level is stabilized by the lactose, fat, and protein. The mother should be notified and advised to come to the clinic; however, emergency treatments would not be delayed if she cannot be located. Asking the child to describe how she feels is appropriate, but taking time to elicit details of history from a 4-year-old child with hypoglycemia is not a good use of time in the immediate situation. The pediatrician should be alerted about the child's condition; however, oxygen is not needed, and it is unlikely that IV access is required at this time

26. The nurse establishes that Rebecca has poor airway clearance. Which intervention is most important for the nurse to implement for this problem? 1. Increased fluid requirements 2. Inhaled corticosteroids 3. Oxygen therapy 4. Flutter valve with huffing

Ans: 4 Forced expiration and huffing is an effective method to clear the airways. Children with cystic fibrosis do not have increased fluid requirements. The use of inhaled corticosteroids has not been demonstrated to improve pulmonary function in children with cystic fibrosis. Oxygen therapy is administered for impaired oxygenation

17. Daisy's mother arrives at the clinic, and she is relieved to find Daisy happy and smiling, but the mother bursts into tears and begins to yell at her neighbor and the nursing staff for "not taking care of her!" What is the best way to handle her anger and tears? 1. Remind the mother that the child is okay and that the neighbor was doing what she thought was best based on the information that she had. 2. Allow the mother to express her feelings and then take the neighbor aside and explain that the mother is just temporarily upset. 3. Teach the mother about ways to communicate the child's needs to all caregivers and help her make a list of specific instructions. 4. Direct the mother to a private area and encourage her to ventilate feelings; then gently assess how she typically manages Daisy's diabetes.

Ans: 4 The mother is very emotional, and she must be allowed to express her feelings first. In addition, accusing others of "not taking care of her" suggests that the mother may be using the defense mechanism of projection (transferring feelings and inadequacies of self onto others). Her anger and fear may be related to guilt for not appropriately informing the neighbor about the child's health condition. The nurse could consider using the other three options after allowing the mother to express herself and further assessing the situation.

Eight-year-old Charlie had a laparoscopic appendectomy. During surgery, the appendix perforated. Charlie arrives on the pediatric unit from the operating room. His weight on admission was 46 lbs (21 kg). He has a peripheral IV line in the left basilic vein with D5W and 20 mEq/L (20 mmol/L) of KCl running at 70 mL/hr. A nasogastric tube (NG) is attached to low suction. 32. Which assessment should be most concerning to the nurse? 1. Oral temperature of 100.4°F (38°C) 2. Decreased bowel sounds in all quadrants 3. Urine output of 160 mL over 4 hours 4. Respiratory rate of 15 breaths per minute

Ans: 4 The respiratory rate is low and indicates possible postoperative atelectasis. It is expected that after a perforated appendix, the patient may have a slightly elevated temperature and decreased bowel sounds. A urine output of 160 mL over 4 hours is normal based on 1 to 2 mL/kg/hr.

23. The pediatric social worker has just informed Ms. A that CPS has been notified and that a representative will arrive shortly to speak with her about the family's situation. Ms. A starts to cry and threatens to leave. What is the priority action? 1. Obtain an "against medical advice" (AMA) form and have her sign it. 2. Notify the pediatrician of the mother's intent to leave. 3. Inform the mother that the police will be notified if she leaves. 4. Encourage Ms. A to remain and to express feelings and fears

Ans: 4 Try to use therapeutic communication first. An AMA form is not appropriate in this situation because the mother's ability to make good judgments and to care for her children is a concern. The pediatrician should be notified because the mother may respond to the pediatrician's advice if she will not listen to anyone else; however, therapeutic communication should be the first intervention. Threatening to call the police is likely to increase the mother's agitation and fears.