Chapter 41: The Child With Gastrointestinal Dysfunction

31. A mother shares with the clinic nurse that she has been giving her 4 year old the antidiarrheal drug loperamide. What conclusion should the nurse arrive at based on knowledge of this classification of drugs? a. Not indicated b. Indicated because it slows intestinal motility c. Indicated because it decreases diarrhea d. Indicated because it decreases fluid and electrolyte losses

ANS: A Antimotility medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children.

Chapter 41: The Child With Gastrointestinal Dysfunction Perry: Maternal Child Nursing Care, 6th Edition MULTIPLE CHOICE 1. Nurses must be alert for increased fluid requirements when a child presents with which possible concern? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP)

ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.

8. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with which intervention? a. Intravenous fluids b. Oral rehydration solution (ORS) c. Clear liquids, 1 to 2 ounces at a time d. Administration of antidiarrheal medication

ANS: A Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

20. What is the earliest clinical manifestation of biliary atresia? a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling

ANS: A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth, but is usually not apparent until ages 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.

24. What is the most appropriate nursing action when a child with a probable intussusception has a normal, brown stool? a. Notify the practitioner b. Measure abdominal girth c. Auscultate for bowel sounds d. Take vital signs, including blood pressure

ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.

27. What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal b. Rice cake c. Corn muffin d. Meat patty

ANS: A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.

16. What condition is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn's disease b. Ulcerative colitis c. Meckel's diverticulum d. Irritable bowel syndrome

ANS: A The chronic inflammatory process of Crohn's disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckel's diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

4. What is a common cause of acute diarrhea? a. Hirschsprung's disease b. Antibiotic therapy c. Hypothyroidism d. Meconium ileus

ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprung's disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.

11. A 4-month-old infant diagnosed with gastroesophageal reflux disease (GERD) is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

ANS: B Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.

3. An infant is brought to the emergency department with poor skin turgor, sunken fontanel, lethargy, and tachycardia. This is suggestive of which condition? a. Overhydration b. Dehydration c. Sodium excess d. Calcium excess

ANS: B These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.

32. Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines

ANS: B Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.

15. Which statement is most descriptive of Meckel's diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

ANS: C Blood stools are often a presenting sign of Meckel's diverticulum. It is associated with mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 2% of the general population. The standard therapy is surgical removal of the diverticulum.

9. Constipation has recently become a problem for a school-age child who is being treated for seasonal allergies. The nurse should focus the assessment on what possibly related factor? a. Diet b. Allergies c. Antihistamines d. Emotional factors

ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies, or emotional factors. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.

17. What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications

ANS: C Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.

13. Which clinical manifestation would most suggest acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point

ANS: D Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.

25. An important nursing consideration in the care of a child with celiac disease is to facilitate which intervention? a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and Standard Precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms.

ANS: A The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.

19. The best chance of survival for a child with cirrhosis is: a. liver transplantation. b. treatment with corticosteroids. c. treatment with immune globulin. d. provision of nutritional support.

ANS: A The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures, such as treatment with corticosteroids or immune globulin and nutritional support, to prevent or treat cirrhosis.

18. Bismuth subsalicylate may be prescribed for a child with a peptic ulcer to effect what result? a. Eradicate Helicobacter pylori b. Coat gastric mucosa c. Treat epigastric pain d. Reduce gastric acid production

ANS: A This combination of drug therapy is effective in the treatment and eradication of H. pylori. It does not bring about any of the results.

21. The nurse, caring for a neonate with a suspected tracheoesophageal fistula, should include what intervention into the plan of care? a. Elevating the head to facilitate secrete drainage. b. Elevating the head for feedings only. c. Feeding glucose water only. d. Avoiding suctioning unless the infant is cyanotic.

ANS: A When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees to maintain an airway and facilitate drainage of secretions. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feeding of fluids should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

3. Which interventions should a nurse implement when caring for a child with hepatitis? (Select all that apply.) a. Provide a well-balanced, low-fat diet. b. Schedule playtime in the playroom with other children. c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling because the child will not be able to return to school. e. Instruct parents on the importance of good hand washing.

ANS: A, C, E The child with hepatitis should be placed on a well-balanced, low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital, so playtime with other hospitalized children is not scheduled. The child will be on contact isolation for a minimum of 1 week after the onset of jaundice. After that period, the child will be allowed to return to school.

MULTIPLE RESPONSE 1. The nurse, caring for an infant whose cleft lip was repaired, should include which interventions into the infant's postoperative plan of care? (Select all that apply.) a. Postural drainage b. Petroleum jelly to the suture line c. Elbow restraints d. Supine and side-lying positions e. Mouth irrigations

ANS: B, C Apply petroleum jelly to the operative site for several days after surgery. Elbows are restrained to prevent the child from accessing the operative site for up to 7 to 10 days. The child should be positioned on back or side or in an infant seat. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.

2. Which statements regarding hepatitis B are correct? (Select all that apply.) a. Hepatitis B cannot exist in a carrier state. b. Hepatitis B can be prevented by hepatitis B virus vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. The onset of hepatitis B is insidious. e. Immunity to hepatitis B occurs after one attack.

ANS: B, C, D, E The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B can exist in a carrier state.

6. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care? (Select all that apply.) a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.

ANS: B, D The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.

4. The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing? (Select all that apply.) a. Nothing by mouth for 24 hours b. Administration of analgesics for pain c. Ice bag to the incisional area d. Intravenous (IV) fluids continued until tolerating fluids by mouth e. Clear liquids as the first feeding

ANS: B, D, E Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given round the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing.

7. Therapeutic management of the child with acute diarrhea and dehydration usually begins with what intervention? a. Clear liquids b. Adsorbents such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric

ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended and neither are antidiarrheal because they do not get rid of pathogens.

5. The viral pathogen that frequently causes acute diarrhea in young children is: a. Giardia organisms. b. Shigella organisms. c. Rotavirus. d. Salmonella organisms.

ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.

14. When caring for a child with probable appendicitis, the nurse should be alert to recognize what sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention

ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

26. What is the major focus of the therapeutic management for a child with lactose intolerance? a. Compliance with the medication regimen b. Providing emotional support to family members c. Teaching dietary modifications d. Administration of daily normal saline enemas

ANS: C Simple dietary modifications are effective in the management of lactose intolerance. Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet. Medications are not typically ordered in the management of lactose intolerance. Providing emotional support to family members is not specific to this medical condition. Diarrhea is a manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel elimination.

12. What is the primary purpose of prescribing a histamine receptor antagonist for an infant diagnosed with gastroesophageal reflux? a. Prevent reflux b. Prevent hematemesis. c. Reduce gastric acid production. d. Increase gastric acid production.

ANS: C The mechanism of action of histamine receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. None of the remaining options are modes of action of histamine receptor antagonists but rather desired effects of medication therapy.

23. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation

ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.

28. Which description of a stool is characteristic of intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. "Currant jelly" stools d. Loose, foul-smelling stools

ANS: C With intussusception, passage of bloody mucus-coated stools occurs. Pressure on the bowel from obstruction leads to passage of "currant jelly" stools. Ribbon-like stools are characteristic of Hirschsprung's disease. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

5. A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber? (Select all that apply.) a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots

ANS: C, D, E High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocados are high in fiber.

22. Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia

ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.

29. What should the nurse stress in a teaching plan for the mother of an 11-year-old diagnosed with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers

ANS: D Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.

30. Careful hand washing before and after contact can prevent the spread of which condition in day care and school settings? a. Irritable bowel syndrome b. Ulcerative colitis c. Hepatic cirrhosis d. Hepatitis A

ANS: D Hepatitis A is spread person to person, by the fecal-oral route, and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis and cirrhosis are not infectious.

2. Which type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Isosmotic dehydration c. Hypotonic dehydration d. Hypertonic dehydration

ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

33. An infant diagnosed with pyloric stenosis experiences excessive vomiting that can result in which condition? a. Hyperchloremia b. Hypernatremia c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

10. Therapeutic management of most children with Hirschsprung's disease is primarily: a. daily enemas. b. low-fiber diet. c. permanent colostomy. d. surgical removal of affected section of bowel.

ANS: D Most children with Hirschsprung's disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprung's disease is usually temporary.

6. A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition? a. Protein intolerance b. Parasitic infection c. Fat malabsorption d. Bacterial gastroenteritis

ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.