Final Exam Ch. 19,20,24,26
An 8-month-old infant is brought to the clinic for evaluation. The mother tells the nurse that she has noticed some white patches on the infant's tongue that look like curdled milk after breastfeeding. The nurse suspects oral candidiasis (thrush). Which question would the nurse use to help confirm this suspicion? A) "Are you having breast pain when you nurse the baby?" B) "Has he had any dairy problems recently?" C) "Is he experiencing any vomiting lately?" D) "How have his stools been this past week?"
A) "Are you having breast pain when you nurse the baby?" The infant may develop thrush from the mother if the mother has a fungal infection of the breast. Asking the mother about breast pain would be important because this type of infection can cause the mother a great deal of pain with nursing. Dairy products are not associated with oral candidiasis but are associated with the development of infectious diarrhea in infants. Vomiting is unrelated to thrush. The infant also may have candidal diaper rash, but this would be manifested on the skin as a beefy-red rash with satellite lesions, not in his stools.
The nurse is educating the parents of a 4-year-old boy with a Wilms tumor who is about to have chemotherapy prior to surgery. Which statement by the parents indicates that the nurse should review the instructions about preventing infection? A) "He takes his antibiotic twice a day." B) "We check his temperature orally." C) "We keep him away from crowds." D) "He must be clean and his teeth brushed."
A) "He takes his antibiotic twice a day." The parents have heard the instructions for the antibiotic administration incorrectly. The trimethoprim-sulfamethoxazole should be administered twice daily for 3 consecutive days each week to prevent Pneumocystis pneumoniae. The parents understand to avoid rectal temperatures and crowds, and to maintain his hygiene meticulously.
The nurse is taking a health history of an 11-year-old girl with recurrent abdominal pain. Which response would lead the nurse to suspect irritable bowel syndrome? A) "I always feel better after I have a bowel movement." B) "I don't take any medicine right now." C) "The pain comes and goes." D) "The pain doesn't wake me up in the middle of the night."
A) "I always feel better after I have a bowel movement." In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of medications and pain that comes and goes or wakes the person up in the middle of the night are all relevant findings pertinent to recurrent abdominal pain.
The nurse is caring for a child with thalassemia who is receiving chelation therapy at home using a battery-operated pump. After teaching the parents about this treatment, which statement by the mother indicates a need for additional teaching? A) "I can have the nurse administer the chelation therapy if I am uncomfortable." B) "I must be very careful to strictly adhere to the chelation regimen." C) "The deferoxamine binds to the iron so it can be removed from the body." D) "The medication can be administered while my child is sleeping."
A) "I can have the nurse administer the chelation therapy if I am uncomfortable." The nurse needs to emphasize to the mother that therapy must be maintained at home to continuously decrease the iron levels in the child's body. Family members need to be taught to administer deferoxamine subcutaneously with a small battery-powered infusion pump over a several-hour period each night (usually while the child is sleeping).
The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which response from the mother indicates a need for further teaching? A) "I should position him on his abdomen with knees bent." B) "He will require 250 to 500 mL of enema solution." C) "I should wash my hands and then wear gloves." D) "He should retain the solution for 5 to 10 minutes."
A) "I should position him on his abdomen with knees bent." A 5-year-old child should lie on his left side with his right leg flexed toward the chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of solution, washing hands and wearing gloves, and retaining the solution for 5 to 10 minutes are appropriate responses.
The nurse is caring for a 3-year-old girl with short bowel syndrome as a result of trauma to the small intestine. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. How should the nurse respond? A) "I will help you become an expert on your daughter's care." B) "You must learn how to care for your daughter at home." C) "You really need the support of your husband." D) "There is a lot to learn and you need a positive attitude."
A) "I will help you become an expert on your daughter's care." The nurse needs to empower families to become the experts on their children's needs and conditions via education and participation in care. The most positive approach in this case is to let the mother know the nurse will support her and help her become an expert on her daughter's care. Telling the mother that she must learn how to care for her daughter or that she must have a positive attitude is not helpful. Telling her that she needs the support of her husband is irrelevant and unhelpful.
After assessing a child's blood pressure, the nurse determines the pulse pressure and finds that it is narrowed. What would the nurse identify as associated with this finding? A) Aortic stenosis B) Patent ductus arteriosus C) Aortic insufficiency D) Complete heart block
A) Aortic stenosis A narrowed pulse pressure is associated with aortic stenosis. A widened pulse pressure is associated with patent ductus arteriosus, aortic insufficiency, fever, anemia, or complete heart block.
The nurse is reviewing the laboratory test results of a child who is receiving chemotherapy. To calculate the child's absolute neutrophil count, in addition to the total number of white blood cells, which results would the nurse use? Select all that apply. A) Bands B) Segs C) Eosinophils D) Basophils
A) Bands B) Segs To calculate the absolute neutrophil count, the nurse would add together the percentage of banded and segmented neutrophils and then multiply the total number of white blood cells reported on the complete blood count by the sum.
A child with heart failure is receiving supplemental oxygen. The nurse understands that in addition to improving oxygen saturation, this intervention also has what effect? A) Cause vasodilation B) Increase pulmonary vascular resistance C) Promote diuresis D) Mobilize secretions
A) Cause vasodilation Oxygen improves oxygen saturaNtiUonRSaInNdGaTlBso.CfOuMnctions as a vasodilator and decreases pulmonary vascular resistance. Diuretics promote dieresis. Chest physiotherapy helps to mobilize secretions.
A 14-year-old boy is diagnosed with Hodgkin disease. When palpating for enlarged lymph nodes, the nurse would expect to find which nodes as most commonly enlarged? Select all that apply. A) Cervical B) Axillary C) Supraclavicular D) Occipital E) Inguinal
A) Cervical C) Supraclavicular Enlarged lymph nodes may feel rubbery and tend to occur in clusters. Although any lymph nodes may be involved, the lymph nodes most commonly affected are in the cervical and supraclavicular areas
When evaluating the hemogram of an 8-month-old infant, the nurse would identify which type of hemoglobin as being the predominant type? A) Hemoglobin A B) Hemoglobin F C) Hemoglobin A2 D) Hemoglobin S
A) Hemoglobin A Three types of normal hemoglobin are present at any given time in the blood: A, F, and A2. By 6 months of age, hemoglobin A is the predominant type. Hemoglobin S is associated with sickle cell disease.
The parents bring their 4-year-old son to the emergency department. The child is receiving chemotherapy for acute lymphoblastic leukemia. The parents report that the child has become lethargic and has had significant episodes of vomiting and diarrhea. Why findings would lead the nurse to suspect the child may be experiencing tumor lysis syndrome? Select all answers that apply. A) Hyperkalemia B) Hypophosphatemia C) Polyuria D) Hypocalcemia E) Hyperuricemia
A) Hyperkalemia D) Hypocalcemia E) Hyperuricemia Tumor lysis syndrome is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, decreased or absent urine output, and hypocalcemia.
A child is diagnosed with Kawasaki disease and is in the acute phase of the disorder. What would the nurse expect the physician to prescribe? Select all that apply. A) Intravenous immunoglobulin B) Ibuprofen C) Acetaminophen D) Aspirin E) Alprostadil
A) Intravenous immunoglobulin C) Acetaminophen D) Aspirin In the acute phase, high-dose aspirin in four divided doses daily and a single infusion of intravenous immunoglobulin are used. Acetaminophen is used to reduce fever. Nonsteroidal anti-inflammatory agents such as ibuprofen are avoided while the child is receiving aspirin therapy. Alprostadil is used to temporarily keep the ductus arteriosus patent in infants with ductal-dependent congenital heart defects.
The nurse is caring for a 13-year-old boy with acute myelogenous leukemia who is experiencing feelings of powerlessness due to the effects of chemotherapy. What intervention will best help the teen's sense of control? A) Involving the boy in decisions whenever possible B) Acknowledging the boy's feelings of anger with the disease C) Providing realistic expectations of treatments and outcomes D) Recognizing abilities that are unaffected by the disease
A) Involving the boy in decisions whenever possible Involving the boy in the decision-making process will best help his sense of control. Whether he is included in important decisions about therapy or minor decisions like menus or dress, it will give him a sense of control over his situation. Acknowledging feelings of anger, recognizing his abilities, and providing realistic expectations will reduce body image disturbance and build self-esteem.
The nurse is providing care to a child with pancreatitis. When reviewing the child's laboratory test results, what would the nurse expect to find? Select all that apply. A) Leukocytosis B) Decreased C-reactive protein C) Elevated serum amylase levels D) Positive stool culture E) Decreased serum lipase levels
A) Leukocytosis C) Elevated serum amylase levels With pancreatitis, serum amylase and lipase levels are elevated and levels three times the normal values are extremely indicative of pancreatitis. Leukocytosis is common with acute pancreatitis. C-reactive protein levels may be elevated. Stool cultures are not used to evaluate this disorder. Positive stool cultures would indicate a bacterial cause of diarrhea.
The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults? A) Most childhood cancers affect the tissues rather than organs. B) Childhood cancers are usually localized when found. C) Unlike adult cancers, childhood cancers are less responsive to treatment. D) The majority of childhood cancers can be prevented.
A) Most childhood cancers affect the tissues rather than organs Childhood cancers usually affect the tissues, not the organs, as in adults. Metastasis often is present when the childhood cancer is diagnosed. Childhood cancers, unlike adult cancers, are very responsive to treatment. Unfortunately, little is known about cancer prevention in children
The nurse is conducting a physical examination of a toddler with suspected lead poisoning. Lab results indicate blood lead level 52 mcg/dL. Which action would the nurse expect to happen next? A) Repeat testing within 2 days and prepare to begin chelation therapy as ordered. B) Repeat testing within 1 week with education to decrease lead exposure. C) Confirm with repeat testing in 1 month and referral to local health department. D) Prepare to admit child to begin chelation therapy.
A) Repeat testing within 2 days and prepare to begin chelation therapy as ordered. The recommendation for blood lead levels of 45 to 69 mcg/dL is to confirm the level with a repeat laboratory test within 2 days and educate the parents to decreased lead exposure. She should also expect to begin chelation therapy as ordered and refer the case to the local health department for investigation of home lead reduction with referrals for support services. Repeat testing in 1 week with parent education is appropriate for lead levels between 20 and 44 mcg/dL. Repeat testing in 1 month and education would be appropriate for levels between 15 and 19 mcg/dL. Preparing to admit the child to begin chelation therapy immediately would be appropriate for lead levels greater than 70 mcg/dL.
When providing care to a child with aplastic anemia, which nursing diagnosis would be the priority? A) Risk for injury B) Imbalanced nutrition, less than body requirements C) Ineffective tissue perfusion D) Impaired gas exchange
A) Risk for injury For the child with aplastic anemia, safety is of the utmost concern, with injury prevention essential to prevent hemorrhage. Nutrition, tissue perfusion, and gas exchange may or may not be associated with the child's condition.
A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper gastrointestinal (GI) series. Before providing instructions, what would be the priority? A) Screening the girl for pregnancy B) Reminding her to drink plenty of fluids after the procedure C) Ordering a bowel preparation D) Reminding the girl about potential light-colored stools
A) Screening the girl for pregnancy Females of reproductive age must be screened for pregnancy prior to the test because radiography is used. A bowel preparation is not necessary for a barium swallow/upper GI series. The reminders about fluids and light-colored stools are appropriate but are not the first priority.
The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which finding would the nurse most likely expect to assess if the child had transposition of the great vessels? A) Significant cyanosis without presence of a murmur B) Abrupt cessation of chest output with an increase in heart rate/filling pressure C) Soft systolic ejection D) Holosystolic murmur
A) Significant cyanosis without presence of a murmur Significant cyanosis without presence of a murmur is highly indicative of transposition. Abrupt cessation of chest output accompanied by an increase in heart rate and filling pressure is indicative of cardiac tamponade. A soft systolic ejection or holosystolic murmur can be found with other disorders, such as hypoplastic left heart syndrome, but is not highly suspicious of transposition.
The nurse is assessing a 13-year-old girl with a family history of kidney cancer who has come to the clinic complaining of abdominal pain, nausea, and vomiting. Which finding would the nurse identify as least likely indicative of cancer in a child? A) The child reports rectal bleeding and diarrhea. B) Observation reveals an asymmetric abdomen. C) The child experiences a broken bone without trauma. D) Palpation determines an abdominal mass.
A) The child reports rectal bleeding and diarrhea. Rectal bleeding and diarrhea are symptoms of rectal cancer in adults and are not typical of children with cancer. The child reporting that a bone broke without any trauma, the nurse observing asymmetric swelling in the abdomen, or palpation revealing a mass in the abdomen are findings in children with cancer.
A group of students are reviewing information about gallbladder disease in children. The students demonstrate a need for additional review when they state: A) cholesterol gallstones are more frequently found in males. B) pigment stones are found primarily in the common bile duct. C) pancreatitis is a common complication of cholecystitis in children. D) cholecystitis is due to chemical irritation from obstructed bile flow.
A) cholesterol gallstones are more frequently found in males. Cholesterol gallstones are seen more often in females than males and increased risk occurs with age and onset of puberty. Pigment stones are usually found in the common bile duct. Pancreatitis is a common complication in children with gallstone disease. Cholecystitis is an inflammation of the gallbladder that is caused by chemical irritation due to the obstruction of bile flow from the gallbladder into the cystic ducts.
The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breastfeeding the baby after surgery and wonders if it is possible. How should the nurse respond? A) "There is a good chance that you will be able to breastfeed almost immediately." B) "Breastfeeding is likely to be possible, but check with the surgeon." C) "After the suture line heals, breastfeeding can resume." D) "We will have to wait and see what happens after the surgery."
B) "Breastfeeding is likely to be possible, but check with the surgeon." Postoperatively, some surgeons allow breastfeeding to be resumed almost immediately. However, the nurse needs to advise the mother to check with the surgeon to determine when breastfeeding can resume. Telling the mother that she has to wait until the suture line heals may be inaccurate. Telling her to wait and see does not answer her question.
The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching? A) "We should avoid aspirin and drugs like ibuprofen." B) "He can resume participation in football in 2 weeks." C) "Swimming would be a great activity." D) "Our son cannot take any antihistamines."
B) "He can resume participation in football in 2 weeks." The nurse must emphasize to the parents that they need to prevent trauma to their son by avoiding activities that may cause injury. Participation in contact sports like football is not recommended. Aspirin, nonsteroidal anti-inflammatory drugs, and antihistamines should be avoided because they could precipitate anemia. Swimming, a noncontact sport, is an appropriate choice.
A child is scheduled to undergo radiation therapy as part of his treatment plan for newly diagnosed cancer. After teaching the child and parents about this treatment, the nurse determines that additional teaching is needed when the parents state: A) "We should not wash off the markings on his skin." B) "He can use petroleum jelly if the skin becomes reddened." C) "He needs to use a sunscreen with an SPF of 30 or more." D) "He should not apply deodorant to the site."
B) "He can use petroleum jelly if the skin becomes reddened." Aqueous creams and moisturizers may be used on the skin, but not petroleum jelly. Markings on the skin should not be removed or washed off. During and after radiation treatment, the skin will be more photosensitive so the child should use a high-SPF sunscreen of 30 or more. Deodorants and perfumed lotions should not be applied to the radiation treatment site.
The nurse is caring for a 6-month-old with a cleft lip and palate. The mother of the child demonstrates understanding of the disorder with which statements? Select all that apply. A) "My smoking during pregnancy didn't have anything to do with this disorder. Smoking primarily causes low birth weight." B) "I know my baby takes a lot longer to feed than most children this age." C) "It really worries me that my baby may have some other disorders that haven't been detected yet." D) "I wonder if my baby will develop speech problems when language development begins?" E) "Thankfully there are doctors that specialize in correcting this type of disorder."
B) "I know my baby takes a lot longer to feed than most children this age." C) "It really worries me that my baby may have some other disorders that haven't been detected yet." D) "I wonder if my baby will develop speech problems when language development begins?" E) "Thankfully there are doctors that specialize in correcting this type of disorder." Feeding and speech are especially difficult for the child with cleft lip and palate until the defect is repaired. Cleft lip and palate occurs frequently in association with other anomalies and has been identified in more than 350 syndromes. Plastic surgeons or craniofacial specialists, oral surgeons, dentists or orthodontists, and prosthodontists are some of the physicians that specialize in repair of this disorder. The mother is incorrect in stating that smoking is not associated with cleft lip or palate. Maternal smoking during pregnancy is a major risk factor for the disorder.
The mother of a 3-week-old infant old brings her daughter in for an evaluation. During the visit, the mother tells the nurse that her baby is spitting up after feedings. Which response by the nurse would be most appropriate? A) "We need to tell the doctor about this." B) "Infants this age commonly spit up." C) "Your daughter might have an allergy." D) "Don't worry; you're just feeding her too much."
B) "Infants this age commonly spit up." In infants younger than 1 month of age, the lower esophageal sphincter is not fully developed, so infants younger than 1 month of age frequently regurgitate after feedings. Many children younger than 1 year of age continue to regurgitate for several months, but this usually disappears with age. The mother's report is not a cause for concern so the physician does not need to be notified. Additional information would be needed to determine if the infant had an allergy. Although the infant's stomach capacity is small, telling the mother not to worry does not address the mother's concern, and telling her that she is feeding the daughter too much implies that she is doing something wrong
The nurse is performing a gastrointestinal assessment on a 7-year-old boy. The parents are assisting with the history. Which assessment findings are indicative of constipation? Select all that apply. A) "Our child only has 3 to 4 bowel movements per week." B) "Our child complains of pain because his bowel movements are so hard." C) "Our child tells us that his belly hurts a lot of the time." D) "I can tell he holds his bowel movement much of the time because of the way he stands." E) "I find smears of stool in his underwear almost every day."
B) "Our child complains of pain because his bowel movements are so hard." C) "Our child tells us that his belly hurts a lot of the time." D) "I can tell he holds his bowel movement much of the time because of the way he stands." E) "I find smears of stool in his underwear almost every day." Pain, stool withholding behavior (retentive posturing), and encopresis (soiling of fecal contents into the underwear beyond the age of expected toilet training) are all signs of chronic functional constipation. Less than 3 bowel movements is considered constipation.
The nurse is caring for an infant girl with a suspected cardiovascular disorder. Which statement by the mother would warrant further investigation? A) "My baby does not make any grunting noises." B) "The baby seems more comfortable over my shoulder." C) "The baby usually drinks all of her bottle." D) "I don't notice any rapid breathing patterns."
B) "The baby seems more comfortable over my shoulder." The nurse should be alert to statements indicating that the baby seems to be more comfortable when she is sitting up or over her mother's shoulder than when she is lying flat. Grunting or rapid breathing would be a cause for concern. Drinking all of the bottle would be considered normal.
The school nurse is working with a 10-year-old girl with recurrent abdominal pain. The girl's teacher has been less than understanding about the frequent absences and trips to the nurse's office. How should the nurse respond? A) "Be patient; she is trying some new medication." B) "The pain she is having is real." C) "The family is working toward improvement." D) "Please do not add to this family stress."
B) "The pain she is having is real." It is important to educate the teacher that this recurrent abdominal pain is a true pain that the child feels and it is not "in her mind." Telling the teacher not to add to the family's stress or that the family is working toward improvement does not teach. The nurse must have the permission of the family to discuss the girl's medication.
The nurse is caring for a newborn diagnosed with an atrial septal defect (ASD). The parents voice concern and state, "I can't believe this is happening. Will our child be okay?" What is the nurse's best response? A) "If the defect isn't treated it can cause problems such as pulmonary hypertension, heart failure, atrial arrhythmias, or stroke." B) "While each case is different, the majority of these defects correct on their own. Let's see what the tests show, then speak with the doctor." C) "Since there are no symptoms being exhibited right now, your child will likely not require surgery until the age of 3 years." D) "Most children have no symptoms of this defect."
B) "While each case is different, the majority of these defects correct on their own. Let's see what the tests show, then speak with the doctor." While all responses supply correct information about the disorder, the best response is, "While each case is different, the majority of these defects correct on their own. Let's see what the tests show, then speak with the doctor." This individualizes the response to this child, offers realistic hope, and verifies that the physician will need to be consulted to answer questions regarding prognosis.
The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day? A) 1,560 mL B) 1,600 mL C) 1,650 mL D) 1,700 mL
B) 1,600 mL Using the following formula of 100 mL/kg for the first 10 kg, plus 50 mL/kg for the next 10 kg, and then 20 mL/kg fNorUtRhSeINreGmTaBi .nCiOnMg kg, the child would require (100 × 10) + (50 × 10) + (20 × 5) = 1,000 + 500 + 100 = 1,600 mL in 24 hours.
The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the nurse monitors for skin breakdown around the stoma. If redness occurs, what would be most appropriate to promote healing and prevent further skin breakdown? A) Clean the area well with a scented diaper wipe. B) Apply a barrier/healing cream or paste on the skin. C) Use a barrier wafer to attach the appliance. D) Sanitize the area with an alcohol wipe after each diaper change.
B) Apply a barrier/healing cream or paste on the skin The nurse should use a barrier/healing cream or paste on the skin around the stoma to promote healing and prevent further skin breakdown. Diaper wipes that contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin breakdown. The barrier wafer would be helpful, but does not address the skin breakdown.
After teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involving increased pulmonary blood flow? A) Tetralogy of Fallot B) Atrial septal defect C) Hypoplastic left heart syndrome D) Transposition of the great vessels
B) Atrial septal defect Atrial septal defect is an example of a disorder involving increased pulmonary blood flow. Tetralogy of Fallot is a defect involving decreased pulmonary blood flow. Transposition of the great vessels and hypoplastic left heart syndrome are examples of mixed disorders.
A nurse is instituting neutropenic precautions for a child. What information would the nurse most likely include? Select all that apply. A) Placing the child in a semiprivate room B) Avoiding rectal exams, suppositories, and enemas C) Placing a mask on the child when outside the room D) Encouraging an intake of raw fruits and vegetables E) Discouraging fresh flowers in the child's room
B) Avoiding rectal exams, suppositories, and enemas C) Placing a mask on the child when outside the room E) Discouraging fresh flowers in the child's room Generally, neutropenic precautions include placing the child in a private room; avoiding rectal suppositories, enemas, and examinations; placing a mask on the child when outside the room; avoiding the intake of raw fruits and vegetables; and not permitting fresh flowers or live plants in the room.
The nurse is caring for an 8-year-old girl who has been diagnosed with leukemia and will have a variety of tests, including a lumbar puncture, before beginning chemotherapy. What action would be the priorty? A) Applying EMLA to the lumbar puncture site B) Educating the child and family about the testing procedures C) Administering promethazine as ordered for nausea D) Educating the family about chemotherapy and its side effects
B) Educating the child and family about the testing procedures The priority would be educating the child and family about the testing procedures so they know what to expect and understand why the tests are being performed. Applying EMLA to the lumbar puncture site will be done prior to the procedure. The family will be educated about chemotherapy and its side effects prior to the therapy beginning, and promethazine or other antiemetics will be administered once chemotherapy has begun.
The nurse is developing a plan of care for a child who is receiving cyclophosphamide. What advice would the nurse expect to include? A) Withholding food and fluids from the child during the infusion B) Encouraging frequent voiding during and after the infusion C) Monitoring for signs of anaphylaxis during infusion D) Assessing the child for complaints of bone pain
B) Encouraging frequent voiding during and after the infusion Cyclophosphamide may cause hemorrhagic cystitis. Therefore, the nurse needs to provide adequate hydration and have the child void frequently during and after the infusion to decrease the risk of hemorrhagic cystitis. Fluids need to be encouraged, not withheld. Monitoring for anaphylaxis would be appropriate when asparaginase or etoposide is given. Bone pain is associated with the administration of filgrastim or sargramostim.
The nurse is assessing a child with suspected thalassemia. What would the nurse expect to assess? A) Dactylitis B) Frontal bossing C) Presence of clubbing D) Presence of spooning
B) Frontal bossing The nurse would expect to find skeletal deformities such as frontal or maxillary bossing. Dactylitis is associated with sickle cell anemia. Clubbing and spooning are associated with chronic decreases in oxygen supply.
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find? A) Sausage-shaped mass in the upper midabdomen B) Hard, moveable, olive-shaped mass in the right upper quadrant C) Tenderness over the McBurney point in the right lower quadrant D) Abdominal pain in the epigastric or umbilical region
B) Hard, moveable, olive-shaped mass in the right upper quadrant With hypertrophic pyloric stenosis, a hard, moveable, olive-shaped mass would be palpated in the right upper quadrant. A sausage-shaped mass in the upper midabdomen would suggest intussusception. Tenderness over the McBurney point would be associated with appendicitis. Epigastric or umbilical pain would be associated with peptic ulcer disease.
The nurse is caring for an infant with suspected patent ductus arteriosus. Which assessment finding would the nurse identify as helping to confirm this suspicion? A) Thrill at the base of the heart B) Harsh, continuous, machine-like murmur under the left clavicle C) Faint pulses D) Systolic murmur best heard along the left sternal border
B) Harsh, continuous, machine-like murmur under the left clavicle With patent ductus arteriosus, a harsh, continuous, machine-like murmur (usually loudest under the left clavicle) is heard at the first and second intercostal spaces. A thrill at the base, faint pulses, and systolic murmur heard best along the left sternal border point to aortic stenosis.
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents? A) Explaining to them about the diagnosis and surgery B) Having a wound, ostomy, and continence nurse meet with them C) Reinforcing that the ostomy will be temporary D) Teaching them about the medications used to slow stool output
B) Having a wound, ostomy, and continence nurse meet with them Although explaining about the diagnosis and surgery, reinforcing that the ostomy will be temporary, and teaching them about medications would be appropriate, the parents are voicing concerns about caring for the ostomy. Therefore, having a wound, ostomy, and continence nurse meet with them would address these concerns and help them deal with the anxieties and care of a newly placed stoma.
The nurse is conducting a physical examination of a child with a ventricular septal defect. Which finding would the nurse expect to assess? A) Right ventricular heave B) Holosystolic harsh murmur along the left sternal border C) Fixed split-second heart sound D) Systolic ejection murmur
B) Holosystolic harsh murmur along the left sternal border With ventricular septal defects, there is often a characteristic holosystolic harsh murmur along the left sternal border. Right ventricular heave, fixed split-second heart sound, and systolic ejection murmur are typically found with atrial septal defects.
The nurse is caring for a 5-year-old boy undergoing radiation treatment for a neuroblastoma. Which nursing diagnosis would be most applicable for this child? A) Activity intolerance related to anemia and weakness from medications B) Impaired skin integrity related to desquamation from cellular destruction C) Impaired oral mucosa related to the presence of oral lesions from malnutrition D) Imbalanced nutrition, less than body requirements related to nausea and vomiting
B) Impaired skin integrity related to desquamation from cellular destruction A nursing diagnosis for impaired skin integrity evidenced by desquamation of the radiation site would only be made for a child undergoing radiation therapy. Activity intolerance due to anemia and weakness, impaired oral mucosa evidenced by oral lesions, and malnutrition and anorexia due to nausea and vomiting are diagnoses that are common to both radiation and chemotherapy.
The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. What would the nurse be least likely to include? A) Daily weight assessment B) Maintenance of strict bed rest C) Prevention of infection D) Signs of complications
B) Maintenance of strict bed rest A child with congenital heart disease should be allowed to engage in activity as tolerated, with rest periods frequently throughout the day to prevent overexertion. Daily weights, infection prevention measures, and signs of complications are all appropriate to include when teaching parents of a child with a congenital heart defect.
The nurse is preparing a presentation for a parent group about childhood cancers, focusing on brain tumors in children. What would the nurse describe as the most common type of brain tumor? A) Brain stem glioma B) Medulloblastoma C) Ependymoma D) Astrocytoma
B) Medulloblastoma Of all the types of brain tumors listed, a medulloblastoma is the most common type. It is invasive, is highly malignant, and grows rapidly
The nurse is reviewing the medical record of a child with infective endocarditis. What would the nurse expect to find? Select all that apply. A) White blood cell count revealing leukopenia B) Microscopic hematuria with urinalysis C) Electrocardiogram with prolonged PR interval D) Lungs clear on auscultation E) Petechiae on palpebral conjunctiva
B) Microscopic hematuria with urinalysis C) Electrocardiogram with prolonged PR interval E) Petechiae on palpebral conjunctiva With infective endocarditis, leukocytosis, microscopic hematuria, prolonged PR interval, adventitious lung sounds, and petechiae on the palpebral conjunctiva are noted.
A group of nursing students are reviewing information about inflammatory bowel disease in preparation for a class discussion on the topic. The students demonstrate understanding of the material when they identify which characteristics of Crohn disease? Select all that apply. A) Distributed in a continuous fashion B) Most common between the ages of 10 to 20 years C) Elevated erythrocyte sedimentation rate D) Low serum iron levels E) Tenesmus F) Loss of haustra within bowel
B) Most common between the ages of 10 to 20 years C) Elevated erythrocyte sedimentation rate D) Low serum iron levels Crohn disease is most common between the ages of 10 and 20 years. Erythrocyte sedimentation rate is elevated and serum iron levels are low. Ulcerative colitis is distributed continuously distal to proximal, with tenesmus and loss of haustra within the bowel. Crohn disease is segmental, with disease-free skip areas common, and the bowel wall has a cobblestone appearance.
After teaching the parents of a child diagnosed with celiac disease about nutrition, the nurse determines that the teaching was effective when the parents identify which foods as appropriate for their child? Select all answers that apply. A) Wheat germ B) Peanut butter C) Carbonated drinks D) Shellfish E) Jelly F) Flavored yogurt
B) Peanut butter Foods allowed in a gluten-free diet include peanut butter, carbonated drinks, shellfish, and jelly. Wheat germ and flavored yogurt should be avoided.
The nurse is conducting a physical examination of a child with suspected Crohn disease. Which finding would be the most suspicious of Crohn disease? A) Normal growth patterns B) Perianal skin tags or fissures C) Poor growth patterns D) Abdominal tenderness
B) Perianal skin tags or fissures Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor growth patterns and abdominal tenderness are common to Crohn disease but are also seen with many other conditions. Normal growth patterns would not point to Crohn disease because of problems with absorbing nutrients.
What would be most appropriate to include in the plan of care for a child who has undergone surgery for removal of an astrocytoma? A) Elevating the foot of the bed B) Positioning the child on his unaffected side C) Raising the head of the bed at least 45 degrees D) Administering large volumes of intravenous fluids
B) Positioning the child on his unaffected side Postoperatively, the nurse should position the child on his unaffected side, with the head of the bed flat or at the level prescribed by the neurosurgeon. The foot of the bed is not elevated to prevent increasing intracranial pressure and contributing to bleeding. Fluids are administered carefully to avoid excess fluid intake, which would cause or worsen cerebral edema.
The nurse is evaluating the laboratory test results of a 7-year-old child with a suspected hematologic disorder. Which finding would cause the nurse to be concerned? A) WBC: 5.6 X 103 /mm3 B) RBC: 2.8 X 106 /mm3 C) Hemoglobin: 11.4 mg/dL D) Hematocrit: 35%
B) RBC: 2.8 X 106 /mm3 The RBC listed is below the normal range for a child between the ages of 6 and 16 years (4.0 to 5.2 X 106 /mm3 ). The WBC count, hemoglobin, and hematocrit are within acceptable parameters for a child this age
The nurse is describing the phases of treatment to a child who was diagnosed with leukemia and his parents. How would the nurse describe the induction stage? A) Intense therapy to strengthen remission B) Rapid promotion of complete remission C) Elimination of all residual leukemic cells D) Reduction of risk for centeral nervous system (CNS) disease
B) Rapid promotion of complete remission Induction is done to rapidly produce a complete remission. Consolidation or intensification is the stage when remission is strengthened and leukemic cell burden is reduced. Maintenance attempts to eliminate all residual leukemic cells, and CNS prophylaxis is the stage that attempts to reduce the development of CNS disease.
The nurse is assessing a child with suspected infective endocarditis. Which assessment finding would the nurse interpret as a sign of extracardiac emboli? A) Pruritus B) Roth spots C) Delayed capillary refill D) Erythema marginatum
B) Roth spots Roth spots are splinter hemorrhages with pale centers on the sclerae, palate, buccal mucosa, chest, fingers, or toes, and are signs of extracardiac emboli. Delayed capillary refill time does not point to extracardiac emboli. Wheezing and pruritus are indicative of a hypersensitivity reaction. Erythema marginatum is a classic rash associated with acute rheumatic fever.
When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess? A) Hirsutism or striae B) Strawberry tongue C) Malar rash D) Café au lait spots
B) Strawberry tongue Dry, fissured lips and a strawberry tongue are common findings with Kawasaki disease. Acne, hirsutism, and striae are associated with anabolic steroid use. Malar rash is associated with lupus. Café au lait spots are associated with neurofibromatosis.
A nurse is caring for a newborn with congenital heart disease (CHD). Which finding would the nurse interpret as indicating distress? A) Reduced respiratory rate during feeding B) Subcostal retraction at the time of feeding C) Perspiration on body after feeding D) Feeding lasting for 15-20 minutes
B) Subcostal retraction at the time of feeding Subcostal retraction during feeding is indicative of distress associated with feeding in newborn infants with CHD. Feeding can be a stress to newborns with CHD who are seriously compromised. Additional features indicating distress in infants with CHD include increased respiratory rate, perspiration along the hairline during feeding and feeding time longer than 30 minutes.
The nurse is caring for a child that just returned from a coronary arteriogram in which the catheter was placed through the left femoral artery. Which nursing actions demonstrate knowledge of the procedure? Select all that apply. A) The nurse allows the patient up to the bathroom only. B) The nurse assesses the dorsalis pedis pulse in the left foot. C) The nurse assesses the puncture site frequently. D) The nurse tells the parents that the physician will discuss the results of the procedure with them. E) The nurse assesses the patient's vital signs every 8 hours.
B) The nurse assesses the dorsalis pedis pulse in the left foot. C) The nurse assesses the puncture site frequently. D) The nurse tells the parents that the physician will discuss the results of the procedure with them. The nurse must assess the pulse distal to the puncture site to determine that circulation remains adequate to the extremity. Assessing the puncture site ensures early recognition of bleeding from the site. The physician will be able to inform the parents regarding the results of the procedure after completion. The child should be kept on bedrest for a specified period of time, so they cannot be up to the bathroom. Vital signs will need to be taken more frequently than every 8 hours for early detection of complications.
The nurse is assessing a 3-year-old boy whose parents brought him to the clinic when they noticed that the right side of his abdomen was swollen. What finding would suggest this child has a neuroblastoma? A) The child has a maculopapular rash on his palms. B) The parents report that their son is vomiting and not eating well. C) The parents report that their son is irritable and not gaining weight. D) Auscultation reveals wheezing with diminished lung sounds.
B) The parents report that their son is vomiting and not eating well. Along with the swollen abdomen on one side, the parents reporting that the child is vomiting and anorexic points to the possibility of a neuroblastoma. Observing a maculopapular rash on the child's palms is a sign of graft-versus-host disease. The parents reporting that the child is irritable and not gaining weight suggests a possible brain tumor as well as malabsorption problems. Auscultation revealing wheezing with diminished lung sounds would suggest other problems, not a neuroblastoma.
A child with a suspected cardiovascular disorder is to undergo diagnostic testing and is scheduled for an echocardiogram. When explaining this test to the child, what would the nurse most likely include? A) "This test will check the pattern of how your heart is beating." B) "They'll take a picture of your chest to look at the heart's size." C) "A special wand that picks up sound is used to check your heart." D) "Small patches are attache to your chest to check the heart rhythm."
C) "A special wand that picks up sound is used to check your heart." An echocardiogram is a noninvasive ultrasound procedure using a gel-coated wand that assesses the heart wall thickness, the size of the chambers, valve and septal motion, and the relationship of the great vessels to other cardiac structures. An electrocardiogram reveals the pattern or rhythm of the heart's beating and involves small patches or electrodes attached to the chest. A chest radiograph involves a radiographic film of the chest to determine the size of the heart and its chambers.
An infant with congenital heart disease is to undergo surgery to correct the defect. The mother states, "I guess I'm going to have to stop breastfeeding her." Which response by the nurse would be most appropriate? A) "That's true, but we'll make sure she gets the best intravenous nutrition." B) "Unfortunately, your baby needs more nutrients than what breast milk can provide." C) "Breast milk may help to boost her immune system, so you can continue to use it." D) "She won't be able to suck, so we have to give her fortified formula through a tube."
C) "Breast milk may help to boost her immune system, so you can continue to use it." Breastfeeding a child before and after cardiac surgery may boost the infant's immune system, which can help fight postoperative infection. If breastfeeding is not possible, mothers can pump milk and the breast milk may be given via bottle, dropper, or gavage feeding. In addition, breastfeeding is associated with decreased energy expenditure during the act of feeding.
A 9-year-old child has undergone a cardiac catheterization and is being prepared for discharge. The nurse is instructing the parents and child about postprocedure care. Which statement by the parents indicates that the teaching was successful? A) "This pressure dressing needs to stay on for 5 days from now." B) "He can't eat but he can drink fluids for the next 24 hours." C) "He should avoid taking a bath for about 3 days but he can shower." D) "It's normal if he says he feels like his heart skipped a beat."
C) "He should avoid taking a bath for about 3 days but he can shower." After a cardiac catheterization, the child should avoid tub baths for about 3 days but he can shower or use sponge baths. The pressure dressing should be removed the day after the procedure and a dry sterile dressing or adhesive bandage is applied for the next several days. After the procedure, the child can resume his usual diet. Any reports of fluttering or the heart skipping a beat should be reported.
The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart failure. The nurse is providing teaching about nutrition. Which statement by the mother indicates a need for further teaching? A) "The baby may need as much as 150 calories/kg/day." B) "Small, frequent feedings are best if tolerated." C) "I need to feed him every hour to make sure he eats enough." D) "Gavage feedings may be required for now.
C) "I need to feed him every hour to make sure he eats enough." Although offering small frequent feedings is appropriate if the infant tolerates them, feeding every hour is not necessary. During the acute phase, continuous or intermittent gavage feedings may be needed to help the infant maintain or gain weight. Due to the increased metabolic demands, the infant may require as much as 150 calories/kg/day.
A nurse is working with an adolescent who is slightly overweight and was recently diagnosed with hypertension. They are discussing nutritional management. Which statement by the adolescent demonstrates understanding of the information? A) "I have to make sure that I don't eat a lot of salty foods." B) "I can eat any amount at a meal as long as I don't eat between meals." C) "I should eat plenty of fresh fruits and vegetables." D) "If I skip breakfast, I can eat a much bigger lunch."
C) "I should eat plenty of fresh fruits and vegetables." Nutritional management includes controlling portion sizes, decreasing the intake of sugary beverages and snacks, eating more fresh fruits and vegetables, and eating a healthy breakfast. Salt restriction and potassium or calcium supplements have not been shown to decrease blood pressure in children.
The mother of a 4 week old infant is tearful. She reports the physician has told her that her son has a small atrial septal defect. She reports she is worried and asks the nurse more about the condition. Which statement by the parents best indicates an understanding of the nurse's teaching? A) "This greatly places my son at risk for cardiac failure." B) "If this does not resolve by the time my child is 1 year old he will likely need surgery." C) "Most of the time this condition spontaneously resolves." D) "Since the surgery to correct this condition can be risky my son will need to be at least 40 pounds."
C) "Most of the time this condition spontaneously resolves." Atrial septal defects in children most likely resolve without treatment. Those that are not corrected by the age of 18 months will likely require surgical intervention. When planned, surgery is not usually performed until the child is at least 3 years of age. There is no indication other problems are present so the child is not at an increased risk for cardiac failure.
The nurse is caring for a 13-year-old girl with von Willebrand disease. After teaching the adolescent and her parents about this disorder and care, which response by the parents indicates a need for additional teaching? A) "We need to administer Stimate prior to dental work." B) "We should be aware that she may suffer from menorrhagia." C) "We should administer desmopressin as often as needed." D) "We understand that she may have frequent nosebleeds."
C) "We should administer desmopressin as often as needed." The parents need to know that desmopressin spray Stimate is used for controlling bleeding; the other brands are used for homeostasis and enuresis. Additionally, Stimate should only be used 3 days in a row as lessening of the response (tachyphylaxis) occurs with frequent use. Stimate should be used before dental work. Menorrhagia and nosebleeds may occur.
A nurse is conducting a physical examination of a 5-year-old with suspected iron-deficiency anemia. How would the nurse evaluate for changes in neurologic functioning? A) "Open your mouth so I can look inside your cheeks and lips." B) "Do you have any bruises on your feet or shins?" C) "Will you show me how you walk across the room?" D) "Let me see the palms of your hands and soles of your feet."
C) "Will you show me how you walk across the room?" Neurologic effects of iron deficiency may be demonstrated when the child's ability to sit, stand, and walk are impaired. Inspecting the mouth, looking for bruises, and checking the hands and feet provide information about signs of petechiae, purpura, or pallor.
A child is scheduled for a lower endoscopy. What would the nurse include in the child's plan of care in preparation for this test? A) Explaining about the need to ingest barium B) Establishing an intravenous access for radionuclide administration C) Administering the prescribed bowel cleansing regimen D) Withholding prescribed proton pump inhibitors for 5 days before
C) Administering the prescribed bowel cleansing regimen Prior to a lower endoscopy, the child must undergo bowel cleansing to allow visualization of the lower gastrointestinal tract via a fiberoptic instrument. Barium is ingested for an upper gastrointestinal and/or small bowel series. Radionuclides are used with a hepatobiliary scan. Proton pump inhibitors are withheld for 5 days before a urea breath test.
The nurse is caring for a 9-year-old boy who is having chemotherapy. The nurse is developing a teaching plan for the child and family about nutrition. What instruction would the nurse be least likely to include? A) Emphasizing the intake of grains, fruits, and vegetables B) Featuring high-fiber foods if opioid analgesics are being taken C) Concentrating on consuming primarily high-calorie shakes and puddings D) Avoiding milk products if diarrhea is a problem
C) Concentrating on consuming primarily high-calorie shakes and puddings Providing high-calorie shakes and puddings with diet restrictions can help with weight gain, if that is a problem. However, concentrating on high-calorie shakes and puddings is not a good strategy. It is best to provide a balanced diet emphasizing grains, fruits, and vegetables. If pain is being treated with opioid analgesics, featuring high-fiber foods is important to help relieve constipation. Avoiding milk products is a good idea if diarrhea is a problem because lactose can make diarrhea worse.
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality? A) Greasy B) Clay-colored C) Currant jelly-like D) Bloody
C) Currant jelly-like The child with intussusception often exhibits currant jelly-like stools that may or may not be positive for blood. Greasy stools are associated with celiac disease. Clay-colored stools are observed with biliary atresia. Bloody stools can be seen with several gastrointestinal disorders, such as inflammatory bowel disease.
The nurse is caring for a 5-year-old girl with a disseminated medulloblastoma. What intervention would be most appropriate for this situation? A) Providing emotional support to the parents and siblings of the child B) Recommending support groups for people whose children have cancer C) Encouraging the family to cry and express feelings away from the child D) Educating the family about the disease, and its treatments, and side effects
C) Encouraging the family to cry and express feelings away from the child The outcome of this highly malignant medulloblastoma is often not positive. Helping the family through anticipatory grieving by encouraging the family to cry and express feelings away from the child would be unique to this child's situation. Educating the family about the disease, its treatments, and side effects; recommending support groups; and providing emotional support to the parents and siblings would be appropriate for any child with cancer.
The nurse is reviewing the white blood cell differential of a 4-year-old girl. Which value would lead the nurse to be concerned? A) Bands: 8% B) Segs: 28% C) Eosinophils: 10% D) Basophils: 0%
C) Eosinophils: 10% For a 4-year-old, normally eosinophils range from 0% to 3%; therefore, a result of 10% would be abnormal and a cause for concern. Bands of 8%, segs of 28%, and basophils of 0% are normal values for this age.
Auscultation of a child's heart reveals a loud murmur with a precordial thrill. The nurse documents this as which grade? A) Grade II B) Grade III C) Grade IV D) Grade V
C) Grade IV A grade IV murmur is loud with a precordial thrill. A grade II murmur is soft and easily heard. A grade III murmur is characterized as loud without a thrill. A grade V murmur is characterized as loud, audible without a stethoscope.
A child diagnosed with stage IV neuroblastoma has undergone abdominal surgery to remove the tumor. He is now receiving chemotherapy. Which nursing diagnosis would be most important? A) Risk for infection related to chemotherapy B) Impaired skin integrity related to abdominal surgery C) Grieving related to advanced disease and poor prognosis D) Imbalanced nutrition related to adverse effects of chemotherapy
C) Grieving related to advanced disease and poor prognosis In stage IV neuroblastoma, there is metastasis to the bone, bone marrow, other organs, or distant lymph nodes. Additionally, the tumor was located in the abdomen, which is associated with a poor prognosis. Therefore, the most important diagnosis would be grieving. Although infection, skin integrity, and imbalanced nutrition may be relevant, they would not be the most important.
A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that the physician will most likely order which medication? A) Alprostadil B) Heparin C) Indomethacin D) Spironolactone
C) Indomethacin Indomethacin is the drug typically ordered to close a patent ductus arteriosus. Alprostadil would be indicated to maintain the ductus arteriosus temporarily in infants with ductal-dependent congenital heart defects. Heparin would be used for prophylaxis and treatment of thromboembolic disorders, especially after surgery. Spironolactone would be used to manage edema due to heart failure and to treat hypertension.
During a follow-up visit, the parents of a 5-month-old infant diagnosed with congenital heart disease tell the nurse, "We're just so tired and emotionally spent. All these tests and examinations are overwhelming. We just want to have a normal life. We're so focused on the baby that it seems like our 3-year old is lost in the shuffle." Which nursing diagnosis would the nurse identify as most appropriate? A) Risk for delayed growth and development related to necessary treatments B) Deficient knowledge related to the care of a child with congenital heart disease C) Interrupted family processes related to demands of caring for the ill child D) Fear related to infant's cardiac condition and need for ongoing care
C) Interrupted family processes related to demands of caring for the ill child The statements by the parents indicate that there is disruption in the family resulting from the demands of caring for the ill infant and they verbalized concern about their older child. The child may be at risk for delayed growth and development, but this is not indicated by the parents' statements. The parents may lack knowledge about their infant's condition and they may be experiencing fear about the infant's condition, but the statements reflect issues related to the family functioning.
A child is receiving methotrexate as part of his chemotherapy protocol. The nurse would anticipate administering which agent to counteract the toxic effects of methotrexate? A) Mesna B) Cyclosporine C) Leucovorin D) Nystatin
C) Leucovorin Leucovorin is given as an antidote to methotrexate to reduce its toxic effects. Mesna is given when cyclophosphamide and ifosfamide are used to prevent hemorrhagic cystitis. Cyclosporine is an immunosuppressant used to treat graft-versus-host disease after hematopoietic stem cell transplant. Nystatin is used to treat mucositis or systemic fungal infection.
When examining the abdomen of a child, which technique would the nurse use last? A) Auscultation B) Percussion C) Palpation D) Inspection
C) Palpation Palpation should be the last part of the abdominal examination. Inspection, auscultation, and percussion should be done before palpation.
The nurse is reviewing the laboratory test results of a child diagnosed with disseminated intravascular coagulation (DIC). What would the nurse interpret as indicative of this disorder? A) Shortened prothrombin time B) Increased fibrinogen level C) Positive fibrin split products D) Increased platelets
C) Positive fibrin split products Laboratory test results associated with DIC include positive fibrin split products; prolonged prothrombin time, partial thromboplastin time, bleeding time, and thrombin time; decreased fibrinogen levels, platelets, clotting factors II, V, VIII, and X, and antithrombin III; and increased levels of fibrinolysin, fibrinopeptide A, and positive D-dimers.
Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration? A) Dusky extremities B) Tenting of skin C) Sunken fontanels D) Hypotension
C) Sunken fontanels A child with moderate dehydration would exhibit sunken fontanels. Severe dehydration would be characterized by dusky extremities, skin tenting, and hypotension.
A child with suspected dyslipidemia undergoes laboratory testing. The nurse is reviewing the results. Which finding would the nurse interpret as supporting the diagnosis? Select all that apply. A) Total cholesterol level of 150 mg/dL B) Total cholesterol level of 180 mg/dL C) Total cholesterol level of 220 mg/dL D) LDL level of 90 mg/dL E) LDL level of 120 mg/dL F) LDL level of 140 md/dL
C) Total cholesterol level of 220 mg/dL F) LDL level of 140 md/dL A total cholesterol level over 200 mg/dL and LDL level above 130 mg/dL are considered high and would support the diagnosis of dyslipidemia. Total cholesterol levels between 170 to 199 mg/dL and LDL levels between 110 to 129 mg/dL are considered borderline. Total cholesterol levels less than 170 mg/dL and LDL levels less than 110 mg/dL are acceptable in children
The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to elicit the child's cooperation? A) "Can you cough for me please?" B) "You must blow in this or you might get pneumonia." C) "If you don't try, I will have to get the doctor." D) "Can you blow this cotton ball across the tray?"
D) "Can you blow this cotton ball across the tray?" Children are more likely to cooperate with interventions if play is involved. Encourage deep breathing by playing games. Asking the boy to cough is less likely to engage him. Telling the child he might get pneumonia is not age appropriate and is unhelpful. Threatening to call the doctor is unhelpful and inappropriate. Remember, however, that the incentive spirometer works on the principle of the amount of air inhaled, not exhaled. Having the child take a deep breath prior to blowing the cotton ball is a beginning step.
The nurse is caring for a child recently diagnosed with glucose-6-phosphate dehydrogenase (G6PD) deficiency. The nurse is teaching the parents about triggers that may result in oxidative stress. Which response indicates a need for further teaching? A) "I doubt he will ever eat fava beans, but they could trigger hemolysis." B) "He must avoid exposure to naphthalene, an agent found in mothballs." C) "He must never take methylene blue for a urinary tract infection." D) "My son can never take penicillin for an infection."
D) "My son can never take penicillin for an infection." The nurse should emphasize that penicillin is not a known trigger that may result in oxidative stress and hemolysis. Fava beans, naphthalene, and methylene blue can trigger oxidative stress.
The nurse is caring for a 2-year-old boy with hemophilia. His parents are upset by the possibility that he will become infected with hepatitis or HIV from the clotting factor replacement therapy. Which response by the nurse would be most appropriate? A) "Parents commonly fear the worst; however, the factor will help your child lead a normal life." B) "There are risks with any treatment including using blood products, but these are very minor." C) "Although factor replacement is expensive, there's more financial strain from missing work if he has a bleeding episode." D) "Since dry heat treatment of the factor began in 1986, there have been no reports of virus transmission."
D) "Since dry heat treatment of the factor began in 1986, there have been no reports of virus transmission." The nurse needs to emphasize that since 1986, there have been no reports of virus transmission from factor infusion since the inception of heat treatment of the factor. Telling the parents that there is a minor risk does not teach. Telling the parents that factor is expensive or that it is common to worry does not teach, nor does it address their concerns.
A 7-year-old child with a family history of cardiovascular disease is being screened for hyperlipidemia. When reviewing the child's laboratory test results, which total cholesterol level would be of significant concern? A) 120 mg/dL B) 150 mg/dL C) 180 mg/dL D) 210 mg/dL
D) 210 mg/dL A total cholesterol level greater than 200 mg/dL is considered high and would be of the greatest concern. Levels of 120 mg/dL and 150 mg/dL are considered within the normal range. A level of 180 mg/dL would be considered borderline and significant. However, a level greater than 200 mg/dL would be of greater concern.
The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next? A) Contact the physician. B) Offer a snack and administer another dose. C) Immediately administer another dose. D) Administer next dose as ordered in 12 hours.
D) Administer next dose as ordered in 12 hours. Digoxin should be administered at regular intervals , every 12 hours, 1 hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should not give a second dose and should wait until the next scheduled dose. It is not necessary to contact the physician.
Which test result would the nurse least likely expect to find in a child diagnosed with Wilms tumor? A) Complete blood count (CBC) within normal limits B) Urinalysis positive for blood C) Mass on kidney D) Elevated homovanillic acid (HVA) with 24-hour urine collection
D) Elevated homovanillic acid (HVA) with 24-hour urine collection Levels of HVA and vanillylmandelic acid (VMA) will not be elevated with Wilms tumor; they are elevated with neuroblastoma. CBC, blood urea nitrogen (BUN), and creatinine usually are within normal limits. Urinalysis may reveal hematuria or leukocytes. Renal or abdominal ultrasound would reveal a mass on the kidney.
The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. What recommendation would the nurse include in the teaching plan? A) Frozen yogurt B) Rye bread C) Creamed spinach D) Fruit juice
D) Fruit juice For the child with celiac disease, foods containing gluten such as frozen yogurt, rye bread, and creamed vegetables should be avoided. Fruit juice would be an appropriate suggestion in a gluten-free diet.
The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management? A) Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. B) Use guided imagery and therapeutic touch. C) Administer meperidine as ordered. D) Initiate pain assessment with a standardized pain scale.
D) Initiate pain assessment with a standardized pain scale. The nurse should first initiate pain assessment with a standardized pain scale upon admission and provide frequent evaluations of pain. Administering NSAIDs or meperidine and the use of nonpharmacologic pain management techniques are all appropriate. However, the first action is to assess the child's pain to provide a baseline for future comparison.
The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care? A) Encouraging consumption of fruit juice B) Offering Kool-Aid or popsicles as tolerated C) Encouraging milk products to boost caloric intake D) Maintaining the intravenous (IV) fluid rate as ordered
D) Maintaining the intravenous (IV) fluid rate as ordered The nurse should maintain an IV line and administer the IV fluid as ordered to maintain fluid volume. High-carbohydrate fluids like fruit juice, Kool-Aid, and popsicles should be avoided as they are low in electrolytes, increase simple carbohydrate consumption, and can decrease stool transit time. Milk products should be avoided during the acute phase of illness as they may worsen diarrhea.
The nurse is caring for a 7-year-old girl who is undergoing a stem cell transplant. What information would the nurse include in the child's postoperative plan of care? A) Assessing for petechiae, purpura, bruising, or bleeding B) Limiting blood draws to the minimum volume required C) Administering antiemetics around the clock as ordered D) Monitoring for severe diarrhea and maculopapular rash
D) Monitoring for severe diarrhea and maculopapular rash In the posttransplant phase, monitor closely for symptoms of graft-versus-host disease (GVHD) such as severe diarrhea and maculopapular rash progressing to redness or desquamation of the skin (especially on the palms of the hands or soles of the feet). During chemotherapy in the pretransplant phase, assess for petechiae, purpura, bruising, or bleeding to prevent hemorrhage; administer antiemetics around the clock as ordered to prevent the cycle of nausea, vomiting, and anorexia; and limit blood draws to the minimum volume required to prevent anemia.
A nursing instructor is developing a class presentation about the medications used to treat peptic ulcer disease. Which drug class would the instructor be least likely to include in the presentation? A) Antibiotics B) Proton pump inhibitors C) Histamine antagonists D) Prokinetics
D) Prokinetics Treatment for peptic ulcer disease includes antibiotics if Helicobacter pylori is verified, histamine antagonists, and/or proton pump inhibitors. Prokinetics are used to stimulate the gastrointestinal tract to help empty the stomach faster and promote intestinal motility. They are not used for peptic ulcer disease.
The nurse is caring for a 16-year-old boy with acute myelogenous leukemia who is having chemotherapy and who has incomplete records for varicella zoster immunization. Which is the priority nursing diagnosis? A) Pain related to adverse effects of treatment verbalized by the child B) Nausea related to side effects of chemotherapy verbalized by the child C) Constipation related to the use of opioid analgesics for pain D) Risk for infection related to neutropenia and immunosuppression
D) Risk for infection related to neutropenia and immunosuppression The priority nursing diagnosis is risk for infection related to neutropenia and immunosuppression. The incomplete records for varicella zoster immunization can cause a problem since exposure to chickenpox could cause sepsis, so the nurse should contact the oncologist for approval to administer the vaccine. Certain vaccines are not administered when the child is immunosuppressed, so timing is crucial. Diagnoses for pain and nausea are valid for this child because he is undergoing chemotherapy, but they are not a priority. Likewise, the need for constipation management would not be necessary unless opioid use begins.
A group of students are reviewing information about fluid balance and losses in children in comparison to adults. The students demonstrate a need for additional review when they state that: A) children have a proportionately greater amount of body water than do adults. B) fever plays a greater role in insensible fluid losses in infants and children. C) a higher metabolic rate plays a major role in increased insensible fluid losses. D) the infant's immature kidneys have a tendency to overconcentrate urine.
D) the infant's immature kidneys have a tendency to overconcentrate urine. The young infant's renal immaturity does not allow the kidneys to concentrate urine as well as in older children and adults, placing them at risk for dehydration or overhydration. Children do have a proportionately greater amount of body water than adults, and fever is important in promoting insensible fluid losses in infants and children because children become febrile more readily and their fevers are higher than those in adults. Children also experience a higher metabolic rate, which accounts for increased insensible fluid losses and increased need for water for excretory function.
A nurse is providing care to a child with idiopathic thrombocytopenic purpura with a platelet count of 18,000/mm3 . Which medication would the nurse most likely expect to be ordered? A) Folic acid B) Intravenous immune globulin C) Dimercaprol D) Deferoxamine
B) Intravenous immune globulin Intravenous immune globulin would be used to treat idiopathic thrombocytopenic purpura. Folic acid is used to treat folic acid deficiency anemia. Dimercaprol is used to remove lead from the soft tissue and bone to allow for excretion by the kidneys. Deferoxamine is used to treat iron toxicity.
After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding? A) Janeway lesions B) Jerky movements of the face and upper extremities C) Black lines D) Osler nodes
B) Jerky movements of the face and upper extremities Sydenham chorea is a movement disorder of the face and upper extremities associated with acute rheumatic fever. Janeway lesions, black lines, and Osler nodes are associated with infective endocarditis.
A child is receiving carboplatin as part of a chemotherapy protocol. What would be most important for the nurse to include in the child's plan of care? A) Monitoring for visual changes B) Maintaining adequate hydration C) Using prescribed eye drops to prevent conjunctivitis D) Avoiding administration with food or meals
B) Maintaining adequate hydration When fluorouracil is administered, the nurse must ensure adequate hydration. Monitoring for visual changes is appropriate when giving fludarabine. Eye drops are necessary to prevent conjunctivitis when high doses of cytarabine are administered. Oral mercaptopurine should not be given with meals or food.
After teaching the parents of a 6-year-old how to administer an enema, the nurse determines that the teaching was successful when they state that they will give how much solution to their child? A) 100 to 200 mL B) 200 to 300 mL C) 250 to 500 mL D) 500 to 1,000 mL
D) 500 to 1,000 mL For a school-age child, typically 500 to 1,000 mL of enema solution is given. For an infant, 250 mL or less is used; for a toddler or preschooler, 250 to 500 mL is used.
The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was: A) 140 beats per minute. B) 120 beats per minute. C) 100 beats per minute. D) 80 beats per minute.
D) 80 beats per minute. In an infant, if the apical pulse rate is less than 90 beats per minute, the dose is held and the physician should be notified.
A group of nursing students are reviewing the various drug classes used for cancer chemotherapy. The students demonstrate an understanding of these classes when they identify which agent as an example of a nitrosourea? A) Busulfan B) Thiotepa C) Cisplatin D) Carmustine
D) Carmustine Carmustine is an example of a nitrosourea. Busulfan, thiotepa, and cisplatin are alkylating agents.
A nurse is reviewing the medical record of a child and finds that the child has a grade III murmur. After auscultating the child's heart sounds, how would the nurse document this murmur? A) Loud without a thrill B) Loud with a precordial thrill C) Soft and easily heard D) Loud, audible with a stethoscope
A) Loud without a thrill A grade III murmur is loud without a thrill. Grade II is soft and easily heard. Grade IV is loud with a precordial thrill. Grade V is characterized as loud, audible with a stethoscope.
The nurse is preparing to administer intravenous fluids to manage a child with dehydration. The medical record indicates the child weighs 60 pounds (27.2 kg). How many milliliters will initially be administered? Record your answer using two decimal places.
545.45 Nursing goals for the infant or child with dehydration are aimed at restoring fluid volume and preventing progression to hypovolemia. Provide oral rehydration to children for mild to moderate states of dehydration. Children with severe dehydration should receive intravenous fluids. Initially, administer 20 mL/kg of normal saline or lactated Ringer, and then reassess the hydration status.
